Posttraumatic headache phenotype associated with symptom burden, quality of life after concussion

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Posttraumatic headache (PTH) phenotype is associated with symptom burden and quality of life 3 months after concussion in children aged 8 to 16 years, according to a study published in Jama Network Open.

Each year in the United States, approximately 840,000 children are in an emergency department (ED) for a traumatic brain injury (TBI). Of those, 70% to 90% are considered to have a concussion, and about one-third will report symptoms beyond 1 month, according to the study authors. Multiple risk factors associated with prolonged recovery in children have been identified in previous studies, with emerging research suggesting persisting symptoms after concussion is associated with PTH with migraine features. Since previous studies have been limited by small sample sizes, the primary objective for investigators was to determine if total symptom burden is associated with postacute PTH phenotype, compared with the validated Predicting and Preventing Postconcussive Problems in Pediatrics (5P) clinical risk score, 3 months post concussion.

The study was a secondary analysis of the Advancing Concussion Assessment in Pediatrics (A-CAP) study, a prospective cohort study conducted at 5 Pediatric Emergency Research Canada (PERC) EDs from September 2016 to July 2019. Included were children, adolescents, and teenagers aged 8.0 to 16.99 years with acute (less than 48 hours) concussion or orthopedic (OI) injury. These data were analyzed from April 2022 to December 2022.

In the secondary analysis, a total of 928 participants were included with a mean age of 12.2 (10.5 to 14.3) years and 383 (41.3%) were female. According to authors, if participants had a headache “sometimes or often” on the Health and Behavior Inventory (HBI), they were considered to have a PTH. The HBI is a “20-item valid and reliable measure of postconcussion symptoms in children recommended by the National Institutes of Health (NIH) as a core common data element in the subacute (> 3 days) and chronic (> 3 months) postinjury intervals,” according to the study. Based on a 4-point scale, symptom frequency is rated as: 0, never; 1, rarely; 2, sometimes; and 3, often. These measures result in a score between 0 and 60, with higher scores indicating higher symptom burden. Using modified International Classification of Headache Disorders, 3rd edition, PTH was classified as migraine, nonmigraine headache, or no headache. Self-reported symptoms were collected within 10 days of injury. Self-reported quality of life was measured using Pediatric Quality of Life Inventory-Version 4.0 (PedsQL-4.0), a 23-item questionnaire that uses a 5-point rating scale. The scale consists of 0-4 with 0 indicating “never a problem” and 4 indicating “almost always a problem.” Separate subcomponent scores are present for social functioning, emotional functioning, school functioning, and physical activity.

The total HBI adjusted score for children with migraine was significantly higher compared to children without headache with an estimated mean difference (EMD) of 3.36 (95% CI, 1.13-5.60). HBI was significantly higher in children with migraine compared to children with OI, with an estimated EMD of 3.10 (95% CI, 0.75-6.62), but was not in children with nonmigraine headache; EMD of 1.93 (95% CI, –0.33-4.19). Children with migraine were more likely (odds ratio (OR) 2.13 [95% CI, 1.02-4.45]) to report reliable increases in total symptoms compared to children without headache. Children with migraine had significantly lower PedsQL-4.0 scores compared to children without headache only for physical functioning (EMD of –4.67 [95% CI, –7.86 to –1.48])

In the secondary analysis of children with concussion or OI, investigators found that compared to children with nonmigraine headache, participants with posttraumatic migraine symptoms after a concussion had higher symptom burden and lower quality of life 3 months after the injury. Further, children without PTH reported the highest quality of life and the lowest symptom burden. The authors noted more research, to determine treatment strategies the consider headache phenotype, is warranted.

Reference:

Ierssel JJ van, Tang K, Beauchamp M, et al. Association of posttraumatic headache with symptom burden after concussion in children. JAMA Netw Open. 2023;6(3):e231993-e231993. doi:10.1001/jamanetworkopen.2023.1993