Trauma-Triggered Migraine or Concussion? Sometimes It's Difficult To Tell

Headaches are the most commonly reported symptom of concussion, but could be the result of a disorder called trauma-triggered migraines (TTMs) and not the result of a concussion, says a new case study and literature review. (1)

The study involved a 16-year-old high school football player who complained of consistent recurrent headaches over the previous two seasons.  The headaches started from minutes to hours after sustaining head trauma during practice or games, but did not occur at other times or with other activities.  The athlete's most recent headache had begun 3 days prior to seeking treatment after he made head-to-head contact with a teammate while attempting to make a tackle.  The headache had gotten progressively worse before going away. He denied having other signs of concussion, such as amnesia, loss of consciousness, confusion, nausea, or vomiting, but did report having some dizziness, and sleeping more.  His headache was diffuse, constant, nonthrobbing, and he had sensitivity to light.  His father and younger sister had been treated for migraines.  Because his headache was associated with trauma in football, he was initially diagnosed with a concussion and restricted from sports until symptoms resolved.

Traumatic migraines: characteristics

The initial diagnosis of concussion was then reconsidered and the patient was ultimately diagnosed as having trauma-triggered migraines (TTMs). 

Traumatic migraines:

• are usually so-called 'classic' migraines (one with aura) as opposed to so-called 'common' migraines (one without aura);
• occur most commonly in children and adolescents with a family history of migraines (70% chance of a parent or sibling having such a history)
• are associated with complex neurological disturbances that can last from hours to days;
• can have an initial period of temporary blindness and paralysis on one side of the body (e.g. hemiplegia), often followed with a delay of seconds to hours after trauma by headache;
• do not show up on neuroimaging (CT or MRI);
• can occur with concussion from the same trauma;
• has symptoms which may overlap with concussion, making it difficult to differentiate between the two:
• can be triggered by a concussion, particularly in individuals susceptible to developing TTM and future migraines; and
• put athletes at increased susceptibility to brain injury from trauma.

Because there are no symptoms that distinguish TTM from concussions (since headache is the most common complaint for both conditions), experts recommend that TTM be considered as a possible diagnosis whenever an athlete has recurrent headaches occuring after trauma, particularly where symptoms are consistent with a migraine, and there is a family history of migraines. (1)

"Most of the diagnosis of concussion versus trauma-triggered migraine is based on history, and there are no laboratory or imaging test that can easily distinguish between the two," notes William P. Meehan, III, MD, Director of the Sports Concussion Clinic at Boston Children's Hospital and a MomsTEAM expert. "Thus, athletes, parents, and physicians must be careful when attempting to distinguish between these two entities."

Treatment

Current recommendations for TTM treatment suggest using migraine management guidelines, although there are no large scale studies evaluating treatment for TTM.

Treatment options include:

• ibuprofen, aceteminophen, and triptans
• supplemental oxygen
• beta blockers (propanol and metoprolol), although propanol should be avoided for patients with asthma)
• antiepileptics (topiramate and valproic acid)
  • Topiramate, however, can cause:
    • hypohyrosis (excessive sweating) leading to hyperthermia (e.g. elevated body temperature) and fatigue, which can lead to heat injuries in a competitive athlete
    • parastheia (feeling of "pins and needles" or limb "falling asleep")
    • renal stones
    • weight loss
    • cognitive problems
  • Valproic acid's frequently has side effects, including:
    • weight gain
    • nausea
    • tremor
    • drowsiness
• tricycle antidepressants (amitripyline)
  • effective anti-migraine medication without side effects that would greatly affect athletic performance
  • side effects include:
    • weight gain
    • sedation
    • dry mouth
    • cardiac arrhythmia (although rare, experts recommend that an electrocardiogram (ECG/EKG) be considered before beginning treatment to rule out a rare congenital heart condition called Long QT syndrome)

Caution urged in return to play

Even if TTM is the most likely diagnosis, clinicians need to be cautious with returning athletes to play prematurely if there is uncertainty as to whether an additional diagnosis of concussion is warranted.  

Factors to be taken into account are:

1. the patient's interest in other sports or physical activity;
2. frequency and severity of migraines or history of multiple concussions; and
3. whether the treatment is successful in treating TTM.