Pediatric Post‐Traumatic Headache and Implications for Return to Sport: A Narrative Review

Abstract

Background.-Headache attributed to mild traumatic injury of the head (aka: mild traumatic brain injury, mTBI), frequently abbreviated to Post-Traumatic Headache (PTH), is one of the most common and disabling symptoms after a head injury. PTH often phenotypes to migraine. Evidence for treating PTH in the pediatric population is limited. Widely accepted guidelines do not exist to aid the clinician and there are currently no placebo-controlled trials for the pharmacologic management of PTH in this age group. Recommendations for when to return a child or adolescent to sport if they develop and/or are being treated for persistent PTH (PPTH) are lacking. The objective of this narrative review is to review the implications of returning an adolescent with PPTH to sport.Methods.-Pediatric neurologists with special qualification in headache collaborated on this narrative review. Literature was searched up until Oct 2019 for articles pertaining to PTH, concussion, mTBI, and the return of a pediatric athlete to sport after mTBI. Article inclusion was at the discretion of the authors. There was author consensus regarding all recommendations made.Conclusion.-The authors recommend that strict adherence to the guidelines that return to sport cannot occur until a child is symptom free at rest, off any medication, may be unreasonable in certain situations. Symptom stability is the proposed new concept for return to sport.Abbreviations: CDC Center for Disease Control, mTBI mild traumatic brain injury, PPTH persistent post-traumatic headache, PTH post-traumatic headache, RTP return to play

Post-Traumatic Headache in Children after Minor Head Trauma: Incidence, Phenotypes, and Risk Factors

“…From our data and those in the literature, therefore, it seems appropriate to recommend rest for the first 2–3 days after a MHT and then gradually return to the normal previous levels of physical activity. Moreover, a recent review proposed an algorithm for a proper, gradual return to normal activity levels, favoring 24 to 48 h of both physical and cognitive rest followed by a return, first, to learning activities (i.e., back to school) and to sports only when a full return to school allows symptom stability (no new symptoms emerge and previous symptoms remain stable) [ 52 ].…”

Longitudinal trajectories of posttraumatic headache after pediatric mild traumatic brain injury

“…Additional exclusion criteria for both groups included: 1) any severe injury (i.e., AIS score ≥4); 2) an injury that would interfere with neuropsychological testing (e.g., preferred upper extremity); 3) hypoxia, hypotension, or shock postinjury; 4) involvement of alcohol or drugs during the injury; 5) any prior traumatic brain injury or psychiatric disorder requiring hospitalization; 6) premorbid neurological disorder (apart from migraine) or intellectual impairment; 7) current injury due to abuse or assault; or 8) any MRI contraindication.…”

“…Posttraumatic headache (PTH) is a common symptom after mTBI (3,4), yet its rate, trajectory, risk factors, and clinical presentation in children remain poorly understood (3,5). Acute PTH has been found in up to 96% of pediatric patients, with incidence varying across studies (4). Following mTBI, older children (i.e., 11–18 years) (4–6) and females (5) have shown increased risk of PTH relative to younger children (i.e., ages 5–12 years) and males, but not always (7).…”

“…Acute PTH has been found in up to 96% of pediatric patients, with incidence varying across studies (4). Following mTBI, older children (i.e., 11–18 years) (4–6) and females (5) have shown increased risk of PTH relative to younger children (i.e., ages 5–12 years) and males, but not always (7). Some research suggests that premorbid (i.e., pre-injury) headache history could be another important risk factor (8), but no known study has examined age at injury, sex, and premorbid headache simultaneously as risk factors for PTH in pediatric mTBI.…”

“…Children with mild orthopedic injury (OI) were included for comparison based on their similarity to children with mTBI in key pre- and postinjury factors (12). Rates of PTH at early (i.e., ∼10 days) and chronic postinjury periods were expected to be greater after mTBI than OI, and especially in children who were older, female, and had premorbid headache (4). Finally, PTH characteristics following pediatric mTBI were expected to be consistent with criteria for migraine more often than for TTH or headache not otherwise classified (NOC) (3,7,8).…”