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Migraine History Bodes Poorly for Recovery from Brain Injury

People who live with migraine appear to experience a slower and less complete recovery from traumatic brain injuries, researchers reported at the virtual annual scientific meeting of the American Headache Society.

"People with a pre-injury history of migraine are at risk for more severe concussion symptoms and prolonged recovery from the concussion as well as still having a headache attributed to their head injury," said the lead study author Laura Langer, an analyst with the KITE Research Institute at the Toronto Rehabilitation Institute–University Health Network. "Those with migraines more frequent than once a month are at the greatest risk."

Of those who experienced migraines more than once a month before they suffered their traumatic head injury, 42 percent at week one reported having continuous post-traumatic headaches compared with 18 percent of the patients with pre-accident migraines that were less frequent (p=0.04), Langer reported.

Consistently, more people reported continuous headaches at every check-up compared with patients with less frequent pre-accident migraines, but the differences later on after the trauma did not reach statistical significance, she told Neurology Today At the Meetings.

Langer and colleagues enrolled 302 individuals in the study who filled out a headache questionnaire at week one. Of that group, 116 or 38.1 percent indicated they had a pre-injury history of migraine in their lifetime. Seventy-five percent were female, and the mean age was 33.3 years; 84 percent of the migraineurs had experienced at least one migraine in the past year.

After the first week, about 92 percent of all the participants reported having at least one headache following the head injury, but more headaches were experienced by those with previous migraine, she reported.

"Notably, those with a pre-accident lifetime history of migraine, at week one, had a significantly higher SCAT-3 (Sport Concussion Assessment Tool) symptom score (p<0.001) and symptom severity score (p<0.001) than those without prior migraine, and the elevated scores were maintained throughout all weeks assessed during the 16-week trial (p< 0.001)," Langer reported.

"The group with pre-accident migraines that were more frequent than monthly—27 people—had higher scores on the SCAT-3 (p=0.001) and more symptoms (p=0.027) than those with pre-accident migraines less than monthly at week one and the higher scores were maintained through all weeks assessed (p< 0.0001).

"When the migraine group was split into subgroups of no migraine in the year prior to concussion—less than one migraine per month in the year prior to concussion, and more than one migraine per month in the year before their concussion—the more than one-per-month group had even more symptoms and more severe ratings of their concussion symptoms than the other migraine subgroups and the group without migraines," Langer explained. 

"They are at a greater risk of a prolonged concussion and headache attributed to their concussion recovery compared with people without a history of migraine," she said. "Potentially they have an even higher risk for persisting headache above their pre-concussion baseline and a prolonged recovery from their concussion than those with pre-injury history of migraine but not as frequent."

Previously, the patients enrolled in the Toronto Concussion Study cohort, had been evaluated to determine if their headache status returned to the level prior to the trauma, and were reportedly at 2.5 times the risk of having headaches symptoms above their baseline.

"In this further analysis of the migraine subgroups, we found that greater than one in five patients (22 percent) with pre-injury migraine more than once a month were still experiencing post-traumatic headache above their baseline at 16 weeks post injury. The general cohort was 11 percent with post traumatic headache above baseline at week 16," she said. "However, because of the small sample size in the group that indicated more than one migraine a month in the year prior to their concussion, this was not statistically significant. Participants are prospectively tracked for 16 weeks in the Toronto Concussion Study and we cannot comment on how long beyond the 16 weeks this deficit persists."

Jonathan Gladstone, MD, a Toronto-based neurologist and a co-investigator on the Toronto Concussion Study at Toronto Rehabilitation Institute, told Neurology Today At the Meetings, "When evaluating patients with concussion in the early post-concussion interval, inquiring about pre-injury migraine history would appear prudent to identify those at potential increased risk of slower recovery and more and more intense symptoms."

"Identifying risk factors up front, may aid clinicians by prompting them to maintain closer follow-up with such patients, be more aggressive with lifestyle and non-pharmacologic interventions, provide greater education on the risks of medication overuse headaches and, possibly, earlier institution of acute or prophylactic therapies," Dr. Gladstone said.

Commenting on the study, Matthew S. Robbins, MD, FAAN, associate professor of neurology at Weill Cornell Medicine/NewYork Presbyterian Hospital, said he concurred with the findings of the Toronto group.

"Migraine is highly unpredictable, but in clinical practice, we commonly see that people with a migraine history who sustain a concussion may go on to have more frequent migraine attacks. We also know from population-based studies that having a head injury is a risk factor for migraine to progress to chronic migraine."

"Higher vigilance would be needed in such a population of people with migraine who sustain a concussion," Dr. Robbins said. "Thankfully, we have more treatments than ever to manage migraine, whether an attack frequency increase is associated with a concussion or not, so there should not be hesitation to seek care."

Disclosures: Langer received consulting fees for statistical analysis from Novartis. Dr. Gladstone had no relevant disclosures.

AHS Abstract: Langer L, Bayley M, Lawrence D, et al. Effects of pre-injury migraine frequency on post-traumatic headache recovery in the general adult population: The Toronto Concussion Study.