Headache After Concussion in Children May Lead to Prolonged Recovery

A migraine following a concussion is associated with higher symptom burden and lower quality of life among children.

Children who experienced posttraumatic migraine symptoms following a concussion, compared with those with other types of headache or no headache, were more likely to have greater symptom burden and lower quality of life 3 months after injury. These are the findings of a study published in JAMA Network Open.

Between 70% and 90% of all traumatic brain injuries (TBIs) experienced by children are considered concussions, with about one-third of children reporting symptoms after
1-month. Posttraumatic headache is reported in up to 90% of pediatric patients, most often along with migraine symptoms.

Researchers conducted a secondary analysis of the prospective cohort study, Advancing Concussion Assessment in Pediatric (A-CAP). For the analysis, they included children who were aged 8-17 years who presented with acute concussion or an orthopedic injury at 5 emergency departments in Canada from September 2016 to July 2019.

All children were eligible to be included in the concussion group if they had a history of blunt head trauma that was associated with 1 or more of 3 World Health Organization criteria for definition of a mild TBI. The criteria include observed loss of consciousness for less than 30 minutes, Glasgow Coma Scale score of 13 or 14, and 1 or more acute sign or symptom(s) of concussion, as noted emergency medical personnel. Exclusion criteria for this group include deteriorating neurologic status, underwent neurosurgery, loss of consciousness for more than 30 minutes, posttraumatic amnesia for more than 24 hours, or an Abbreviated Injury Scale (AIS) score higher than 4.

Early identification of migraine after pediatric concussion may inform prognostication and targeted intervention to prevent prolonged recovery.

In the orthopedic injury group, inclusion criteria include injuries that occurred in upper or lower extremities, from blunt trauma associated with an AIS score of 4 or less.

Children were excluded from both groups if they have a previous overnight hospitalization for TBI, a concussion within 3 months, or a neurodevelopmental disorder.

The primary study outcome was child-reported total symptom score on the Health and Behavior Inventory (HBI) and Pediatric Quality of Life Inventory-Version 4.0 (PedsQL-4.0) 3 months following injury. Frequency of symptoms is rated on a 4-point scale, with 0 = never, 1 = rarely, 2 = sometimes, and 3 = often. The possible total score is 0 to 60, with higher scores representing a higher symptom burden. Secondary study outcomes included subscale scores for 11 cognitive symptoms and 9 somatic symptoms.

A total of 928 children of 967 were enrolled in the study. The median age was 12.2 years and 41.3% were female. Among the 928 pediatric participants, 548 had experienced a concussion, including 254 with concussion and migraine headache; 134 with concussion and nonmigraine headache; and 160 with concussion and no headache; and 239 experienced an orthopedic injury without a headache.

Compared with children without headache, those who experienced migraine were more likely to report increases in their total symptoms (odds ratio [OR], 2.13; 95% CI, 1.02-4.45) and their somatic symptoms (OR, 2.70; 95% CI, 1.29-5.68). Additionally, the PedsQL-4.0 subscale scores were significantly lower among children with migraine, compared with those without headache, in terms of physical functioning only (Estimated mean difference [EMD], –4.67; 95% CI, –7.86 to –1.48).

Study limitations included self-reported migraine characteristics rather than a physician diagnosis and a lack of control for clinical interventions that could have affected the outcomes.

“Early identification of migraine after pediatric concussion may inform prognostication and targeted intervention to prevent prolonged recovery,” the researchers noted. “Further research to determine effective treatment strategies that consider headache phenotype is warranted,” they concluded.

Disclosure: Some of the study authors have declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures. 

This article originally appeared on Neurology Advisor


van Ierssel JJ, Tang K, Beauchamp M, et al; Pediatric Emergency Research Canada A-CAP study team. Association of posttraumatic headache with symptom burden after concussion in children. JAMA Netw Open. March 3, 2023. doi:10.1001/jamanetworkopen.2023.1993