kids’ korner By A. David Rothner, MD
Post-Concussion Headache in Sports
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FOR HALEY MANKIN of Newtown Square, Penn., cheerleading was life. She had migraine and New Daily Persistent Headache that appeared at age 13, but that didn’ t stop her from participating in activities and going to school. That is, until a cheerleading competition at age 15. Mankin was at the bottom of a human pyramid when it collapsed; she was hit in the head three times, resulting in a concussion. She doesn’ t remember the moments that followed, although her friends tell her she seemed confused.
“ We weren’ t that panicked,” says her mother, Lisa Goldstein, MD, a child psychiatrist.“ We’ d seen other kids with concussions. We thought she’ d be back to her normal self quickly. It wasn’ t until we started to realize she wasn’ t recovering like other kids that the gravity of the situation began to set in.”
Six weeks after the concussion, Haley’ s migraines increased from her usual two times a month to three times a week. Ten weeks after the trauma, she was hospitalized for nine days with intractable daily migraine and vomiting. Now 17, Haley continues to experience daily headaches and has been diagnosed with post-concussion headache in the form of chronic migraine. She is home-schooled and typically unable to complete more than three non-consecutive hours of schoolwork a day or go to noisy or busy places like the grocery store, movie theater or mall.
Up to 3.8 million recreation- and sport-related concussions occur annually in the United States, according to the Centers for Disease Control and Prevention. Elementary and middle school concussions are less researched and receive less publicity because younger children do not play as many organized sports, do not hit as hard and weigh less. By high school, concussions represent an estimated 8.9 percent of all athletic injuries, according to research published in the Sept. 2010 issue of the journal Pediatrics. Some would suggest girls have a higher rate of concussion, with researchers suggesting a smaller head mass in females may be to blame. However, boys tend to have a higher number of concussions, due to participation in more sports and in contact sports( namely, football).
To avoid post-concussion headaches, concussion prevention in children’ s sports is essential; that includes teaching children how to tackle properly and having the right protective gear. Those who experience post-concussion headaches must seek treatment early to attempt to return to function and a full life.
LINGERING HEADACHES AFTER TRAUMA
Sport-related concussion is an alteration in the functioning of the brain caused by a blow to the athlete’ s head( or body with force transmitted to the head). In most cases, symptoms resolve in seven to 10 days, according to the journal Pediatrics. But sometimes headaches, the most common symptom of concussion, could linger for months.
Post-concussion headache( PCH), a type of posttraumatic headache, is a secondary headache that develops as the result of a concussion. The headaches can present in many forms: tension-type headache, episodic migraine, chronic daily headache or a combination. Those who already had headaches or a family history of headaches prior to the trauma are more likely to experience some form of PCH, and PCH is thought to be more severe in girls with a history of headache. According to the International Classification of Headache Disorders, post-traumatic headaches develop within seven days of the traumatic event. However, most headache specialists agree that if headaches start even within several weeks of the concussion, those headaches can still be considered post-traumatic headaches.
Once diagnosed— generally via a thorough history( including a review of symptoms) followed by a neurological exam— a treatment path is designed based on the specific type of headache that the child is experiencing.
BOUNCING BACK, SLOWLY
Successful treatment isn’ t easy for many PCH sufferers. Excessive use of over-the-counter medications( defined as use more than twice a week), excessive school absences and pain can make it more difficult for children and their parents to reach out to a physician. Yet such complications also point to a need for children with PCH to find treatment.
To improve PCH, headache specialists advise adequate sleep, adequate hydration, educational support and counseling. Exercise is recommended, though physicians will generally advise exercise that starts slowly, increasing over time.
It may also be important to adjust to a new lifestyle, modifying schooling and activities that can exacerbate
Tips for Parents and Children
Dr. Goldstein and her daughter, Haley, offer these tips for children and parents of children who are involved in sports:
TAKE RESPONSIBILITY FOR EDUCATION. Make sure you, your coaches and your school administrators understand the risks for concussion, recurrent concussions, return-to-play guidelines, and evaluation and treatment options.
BE AWARE OF PREDISPOSING FACTORS. Adolescents who have a previous history of headache or a strong family history of headache seem to have more problems with headaches after concussion.
BE OPEN WITH EACH OTHER AND TAKE ACTION. Haley admits that the concussion from the pyramid was likely not the first concussion she’ d had. She had been hit in the head in cheerleading before but says,“ I wasn’ t telling anyone because I didn’ t want my mom to worry or make me quit cheerleading.” It’ s important for children to be honest because they symptoms can worsen if there are recurrent concussions.
STAY OPTIMISTIC.“ Know that it will get better eventually,” Haley says.“ Until then, try to find things that make you happy and find ways to enjoy the life you have.” Haley learned to play guitar, listens to audiobooks and watches the show Glee, which she says has helped her through the hardest days.
symptoms. With that in mind, it would be prudent to enlist the help of an educational counselor who can modify the child’ s schedule and an emotional counselor who can help them work through their feelings about their pain and adjusted lifestyle.
Eventually, treatment should help PCH to resolve on its own, although that resolution may occur at a different point in time for every patient. The majority of individuals with PCH improve within a couple of weeks of the trauma. Haley Mankin represents a smaller proportion of adolescents whose PCH persists. For patients with persistent PCH, it is even more important to see an expert and follow a treatment plan.
“ There’ s always a balance between looking for the next treatment, cure or doctor, versus accepting that for right now this is how she is going to be,” Dr. Goldstein says, of Haley.“ But I never give up hope that she’ ll get better.” Hw
��������������������������������������������������� �������������������������������������������������� Child Neurology at the Cleveland Clinic in Cleveland, ��������������������Head Wise�����������������
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