Mild Head Strike May Have Lasting Impact on Children and Adolescents
Abstract & Commentary
By Dara Jamieson, MD, Associate Professor of Clinical Neurology, Weill Cornell Medical College. Dr. Jamieson reports she is a retained consultant for Boehringer Ingelheim and Bayer, and is on the speakers bureau for Boehringer Ingelheim.
Synopsis: Almost a third of children and adolescents seen in the emergency department with mild traumatic brain injury develop postconcussion syndrome, with migraine-like headaches as the most common symptom.
Sources: Babcock L, et al. Predicting postconcussion syndrome after mild traumatic brain injury in children and adolescents who present to the emergency department JAMA Pediatr 2013;167:156-161.
Butler IJ. Postconcussion syndrome after mild traumatic brain injury in children and adolescents requires further detailed study. JAMA Neurol 2013; March 25:1-2. doi:10.1001/jamaneurol.2013.2801 [Epub ahead of print].
Kuczynski A, et al. Characteristics of post-traumatic headaches in children following mild traumatic brain injury and their response to treatment: A prospective cohort. Dev Med Child Neurol 2013; Apr 5. http://dx.doi.org/10.1111/dmcn.12145.
Mild Traumatic Brain Injury (MTBI) in childhood and adolescence often occurs as a sports injury or after a fall, and can result in disabling symptoms of postconcussion syndrome (PCS), including post-traumatic headaches (PTH). A definition of mTBI developed by the Mild Traumatic Brain Injury Committee of the American Congress of Rehabilitation Medicine is a blow to the head or acceleration/deceleration movement of the head resulting in one or more of the following: loss of consciousness for < 30 minutes, amnesia of < 24 hours or any alteration in mental state, and a Glasgow Coma Scale score of ≥ 13 measured 30 minutes or more after injury.
Babcock et al did a retrospective analysis of a prospective observational study to determine the acute predictors associated with the development of PCS in children and adolescents after mTBI. Four hundred six children and adolescents, ages 5 to 18 years, presented to the pediatric emergency department (ED) at the University of Rochester Medical Center. The Rivermead Post Concussion Symptoms Questionnaire (RPQ) was administered to compare the severity of symptoms present at 3 months after the injury to symptoms that had occurred prior to the injury. Common PCS symptoms included headaches, dizziness, nausea, noise sensitivity, sleep disturbance, fatigue, irritability, depression, frustration, poor memory, poor concentration, taking longer to think, blurred vision, light sensitivity, double vision, and restlessness. PCS was defined as the presence of three or more of these symptoms on the RPQ that were rated as worse than before the injury. Of the patients presenting to the ED with mTBI, 29.3% developed PCS. Headache was the most common symptom after the injury noted on the RPQ, reported by 30.5%. Significant acute predictors for PCS, while controlling for other factors, were adolescent age (odds ratio [OR], 2.00; 95% confidence interval [CI], 1.07-3.73), presence of headache (OR, 2.63; CI, 1.52-4.57), and admission to the hospital (OR, 2.90; CI, 1.48-5.68). All patients experienced considerable school absenteeism after the TBI, but those who developed PCS missed a mean (SD) of 7.4 (13.9) days.
In the experience of Ian Butler, MD, a pediatric neurologist who commented on the Babcock study, the clinical manifestations of PCS usually resolve in 3-6 months; however, behavioral and cognitive changes may take longer (1-2 years). He noted that children with an underlying calcium channelopathy may have delayed severe neurological sequelae after mTBI, out of proportion to the degree of trauma. Given the association between calcium channel disorders and neurological sequelae after mTBI, Butler predicted that gene testing for calcium or other channelopathies eventually may help in predicting outcome after mTBI in children.
Kuczynski et al described the clinical characteristics and response to treatment of PTHs in a prospective cohort of children with mTBI presenting to an ED in Canada. A prospective longitudinal ED cohort with mTBI (n = 670; 385 males, 285 females) was compared to a group of children with extracranial injury (n = 120; 61 males, 59 females). A retrospective chart review of a separate cohort of children from a brain injury clinic (the treatment cohort) treated for PTH was also performed (n = 44; 29 females, 15 males; mean age 14 years 1 month, SD 3 years 1 month). The median time since mTBI was 6.9 months (range 1-29 months) in the treatment group. The mean follow-up interval after treatment started was 5.5 weeks (SD 4.3 weeks). Among the ED cohort (n = 39; 20 males, 19 females; mean age 11 years 1 month, SD 4 years 3 months), 11% of children were symptomatic with PTHs at a mean of 15.8 days (SD 11.6 days) after injury. The morbidity associated with PTH was significant, with 44% and 61% of children in the ED and clinic cohorts, respectively, experiencing daily headaches. Three months after mTBI, 7.8% of children complained of headaches of multiple types (including tension-type, cervicogenic, and occipital neuralgias), with 55% of the mTBI headaches meeting the criteria for migraine. A majority (56%) of children with PTH had pre-existing headaches, with 18% having pre-trauma migraines. A family or past medical history of migraine was present in 82% of cases. Medications used for treatment included amitriptyline, flunarizine (not available in the United States), topiramate, and melatonin, with an overall response rate of 64%.
A significant proportion of children who experience mTBI develop neurocognitive symptoms that cause disability with a major impact on school, social and sports activities, and interactions with friends and family. Identification of which children are at greatest risk of PCS should lead to early intervention and consultation with a specialist to prevent headaches and to individualize treatment of mood and behavioral symptoms. Those children who have prior migraine headaches or a family history of migraine appear to be particularly vulnerable after mTBI and should be watched for the development of PTHs so that preventive medications can be initiated early, before disability escalates. Although many of the symptoms of PCS dissipate with time, not treating the disabling symptoms early and aggressively may cause loss of scholastic and social opportunities that could impact the young person’s life years after the injury.