ARTICLE IN BRIEF
Among collegiate student-athletes with a history of concussion, almost one in three males and nearly one half of females reported having a history of migraine, according to a new report. But the researchers cautioned that the data are insufficient to support any relationship between sport-related concussions and migraines or other headaches.
A survey conducted by the National Collegiate Athletic Association (NCAA) Headache Task Force has found that among collegiate student-athletes with a history of concussion, almost one in three males and nearly one half of females reported having a history of migraine.
Despite these elevated rates, the researchers cautioned that the data are insufficient to support any relationship between sport-related concussions and migraines or other headaches.
While the lifetime prevalence of migraine in the general population is estimated to be around 16 percent, the investigators found that 23.7 percent of 834 surveyed athletes reported a history of migraine, either by medical diagnosis or self-diagnosis. Among those with a history of concussion, 35.9 percent reported a history of migraine — 46.3 percent of women and 32.2 percent of men.
The findings of the initial report from the NCAA task force were published online May 7 in Headache, the journal of the National Headache Society.
Research shows that headache is the most common complaint after concussion, affecting an estimated 93 percent of patients.
“The etiology of increased prevalence of migraine in athletes in our study is unclear,” said lead author Tad D. Seifert, MD, a neurologist and director of the Sports Concussion Program at Norton Healthcare in Louisville, KY.
“We have three different theories,” he told Neurology Today. “First, there is better education and recognition, and therefore better reporting. In addition, we are capturing data in the 18- to 23-year-old age group where the prevalence of migraine is high already, although not as high as our study indicates; and third, we have some evidence that headaches can be sequelae of head trauma.”
Of those reporting a prior history of multiple concussions, 40.4 percent reported a history of migraine and 33.0 percent indicated a history of sinus headache; however, migraines are often misdiagnosed as sinus headache. A 2007 study in Headache found that up to 75 percent of sinus headaches met International Headache Society criteria for migraine or probable migraine.
“It is often unclear whether an athlete has an exacerbation of a primary headache disorder, new-onset headache unrelated to trauma, or has suffered a concussive injury,” Dr. Seifert said, adding that non-traumatic headaches in athletes are often misdiagnosed or overlooked.
“Our primary message is that we need to dig a little deeper to better determine why prevalence is higher than expected in these student-athletes. The NCAA is a good place to start, but we need more studies,” Dr. Seifert said.
The task force will launch the next phase of their research this fall, a prospective review of a large group of collegiate athletes that they will track throughout their athletic careers and perhaps longer.
STUDY DESIGN, FINDINGS
For the current study, the investigators used self-administered questionnaires of 834 athletes at four NCAA Division-I universities, including participants in a variety of sports with differing levels of contact exposure. The survey also collected data on personal and family history of headache.
Among those athletes who reported migraine, either self-diagnosed or by a physician, 27.8 percent played contact/collision sports and 22.9 percent played noncontact sports. A total of 25.2 percent reported a history of sinus headache, and 12.3 percent said they had a history of tension headaches. (For more of the findings, see “The Data on Migraine in Concussed Student Athletes.”)
Collegiate athletes are exposed to many coexisting migraine triggers, including travel and stress, the researchers noted.
“The increased prevalence of migraine seen in our sample is intriguing, as it remains unclear if this represents a genuine trend in a young adult sample routinely exposed to typical migraine triggers,” they wrote.
While post-traumatic headache is often reported after a concussion, the isolated complaint of headache is often discounted after head trauma, according to Dr. Seifert, and even when investigated appropriately, human error can lead to the potential misdiagnosis of migraine or another primary headache disorder.
“Conversely, some athletes competing in contact sports are likely misdiagnosed with concussion when, in fact, they are simply having a primary headache exacerbation. The isolated complaint of headache following trauma does not necessarily indicate a concussive injury has occurred.”
“The findings broadly support the idea that athletes with a history of concussion have more headaches,” said Richard B. Lipton, MD, FAAN, the Lowe Professor and vice chair of neurology at Albert Einstein College of Medicine of Yeshiva University and director of the Montefiore Headache Center in New York.
“Based on research to date, we know that concussions and even sub-concussive injuries, such as those in soccer players, are broadly associated with higher rates of migraine and white matter microstructure alterations.”
One issue with the study's design, he told Neurology Today, was that it relied on self-reported headaches; he noted that it is not uncommon for individuals to misclassify their headaches. “A lot of times patients who report having sinus headaches in fact have migraines, so I suspect the rate of migraines could be higher than the article suggests.”
One of the paper's strengths is that the researchers looked at both sexes and in a broad range of sports, Dr. Lipton said. “I would like to see a longitudinal study using validated methods for headache diagnosis rather than using self-reported frequency, but this is an important first step.”
Dawn Buse, PhD, FAAN, associate professor of neurology and psychology at Einstein College of Medicine and director of behavioral medicine in the Montefiore Headache Program, noted that collegiate student-athletes are often exposed to a variety of common migraine attack triggers, including lack of sleep or changes to the sleep schedule, travel, stress, certain foods, dehydration, physical exertion and alcohol and drug use (both prescription and recreational), that may trigger a higher frequency of attacks.
“In addition, there is a bidirectional relationship between concussion and migraine. The occurrence of one may predispose or amplify the experience of the other,” she told Neurology Today. “This highlights the importance of headache education about healthy lifestyle habits.”
Collegiate student-athletes who experience frequent severe headache and have never been diagnosed or treated by a health care professional should seek medical care, she emphasized.
“Based upon prevalence rates seen in this study and other epidemiologic research, it is likely that they meet criteria for migraine or another primary headache condition that can be managed with a personalized treatment plan including pharmacologic and behavioral approaches.”
“Research has shown that individuals with migraine may be more susceptible to concussion, exacerbation of migraine, new onset of post-traumatic headache and other lingering effects of head trauma,” she noted.
“The current study is an important snapshot, and while it had a good sample size of 834, replication with an even larger sample and more distribution would allow for additional analyses and comparisons.”
Additional data including serum biomarkers and imaging would also be welcome in enhancing understanding headache in collegiate student-athletes, Dr. Buse said.
EXPERTS: ON THE PREVALENCE OF MIGRAINE IN STUDENT ATHLETES
THE DATA ON MIGRAINE IN CONCUSSED STUDENT ATHLETES
Among other findings, researchers reported the following:
- In those who reported a history of concussion, 32.0 percent reported a history of sinus headache versus 25.5 percent of those with no prior concussions.
- Some participants self-reported experiencing multiple subtypes of headache. Among them, 14.6 percent reported having nine or more headaches each month.
- A total of 28.3 percent reported that their headaches were moderate or severe, and almost 85 percent described their headaches as “throbbing, pounding, or pulsating,” and 33.5 percent said they functioned at 75 percent or lower during sports activities due to headache.