Postacute Headache Phenotype Associated With Worsened Symptom Burden, Quality of Life Following Concussion in Children


Compared with children without posttraumatic headache, those who experienced migraine symptoms following concussion were nearly 3 times more likely to report reliable increases in somatic symptoms.

Jacqueline J. van Lerssel, PhD, PT, postdoctoral fellow, Children’s Hospital of Eastern Ontario Research Institute

Jacqueline J. van Lerssel, PhD, PT

Findings from a large-scale study of children with concussion or orthopedic injury (OI) showed that those with posttraumatic headache migraine symptoms had higher symptom burden and lower quality of life 3 months after injury than those with nonmigraine headache, suggesting an association.

Led by Jacqueline J. van Lerssel, PhD, PT, postdoctoral fellow, Children’s Hospital of Eastern Ontario Research Institute, this was a secondary analysis of the Advancing Concussion Assessment in Pediatrics (A-CAP) prospective cohort study. Of the 928 children included, 548 had concussion, including 254 (46.4%) with posttraumatic headache migraine (PTH-M) phenotype, 134 (24.5%) with PTH-nonmigraine (PTH-NM), and 160 (29.2%) with no PTH, and 239 with OI without headache who returned for the postacute visit.

Self-reported postconcussion symptoms and quality of life were measured at 3 months after concussion using the validated Health and Behavior Inventory (HBI) and Pediatric Quality of Life Inventory-Version 4.0 (PedsQL-4.0). The HBI, a 20-item validated tool recommended by the National Institutes of health, used scores ranging from 0 to 60, with higher scores indicating higher symptom burden. Additionally, the 5P clinical risk score was derived and validated previously in a large pediatric sample using variables measured in the emergency department to project the risk of postconcussion symptoms.

In a multivariable model that included 5P risk score, posttraumatic migraine phenotype was found to be significantly associated with total symptom burden (estimated mean difference [EMD], 3.10; 95% CI, 0.75-5.44; P = .01). Of note, the 5P risk score was significant at a univariate level but not in the multivariable model (EMD, 0.26; 95% CI, –0.26 to 0.77; P = .32).

Findings indicated higher total HBI scores in children with PTH-M than for those with no PTH (EMD, 3.36; 95% CI, 1.13-5.60) and for those with OI (EMD, 3.10; 95% CI, 0.75-5.44). Mean HBI total scores were lower for children with PTH-NM relative to those with PTH-M (EMD, –1.93; 95% CI, 0.33 to –4.19) and higher compared with no PTH (EMD, 1.44; 95% CI, –0.95 to 3.92) and those with OI (EMD, 1.17; 95% CI, –1.29 to 3.63).

"Confidence in our data is bolstered by the use of standardized data collection procedures by trained research assistants and rigorous validated outcome measures with good reliability," the study investigators wrote. "Our findings are likely generalizable to children with varying mechanisms of injury, since recruitment was not limited to sport-related concussion. By recruiting from pediatric EDs within 48 hours of injury, we reduced the confounding effect of time to initial assessment, since late clinical care is associated with prolonged recovery."

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At 3 months, children with PTH-M did not differ significantly on cognitive symptoms relative to the other groups; however, this group reported significantly higher somatic symptoms than those with no PTH (EMD, 1.39; 95% CI, 0.43-2.36). In addition to headache phenotype (F = 5.2), preinjury cognitive (F = 24.8) and somatic (F = 11.6) symptoms and sex (F = 8.3) were associated with total symptoms at 3 months. Relative to those with no PTH, children with PTH-M were 2 times more likely to report reliable increases in total symptoms (OR, 2.13; 95% CI, 1.02-4.45) compared with the no PTH group. Additionally, children with PTH-M were nearly 3 times more likely to report reliable increases in somatic symptoms (OR, 2.70; 95% CI, 1.29-5.68) compared with the no PTH group.

In terms of quality of life, the PTH-M group showed lower estimated scores on the PedsQL-4.0 physical activity subscale relative to the no PTH group (EMD, –4.09; 95% CI, –7.00 to –1.18; P = .04). In multivariable models, posttraumatic migraine phenotype was not significantly associated with total quality of life, specifically, PTH-M and PTH-NM groups showed no significant differences in total or PedsQL-4.0 subscale scores.

Using the modified 5P risk score, exploratory data revealed significant differences in PedsQL-4.0 scores between the PTH-M and no PTH groups for total (EMD, –3.49; 95% CI, –5.88 to –1.10; P = .03) and physical functioning (EMD, –4.55; 95% CI, –7.19 to –1.43; P = .03) scores. Notably, this difference was also observed between PTH-M and OI groups for school functioning (EMD, –4.55; 95% CI, –7.66 to –1.43; P = .03), Preinjury cognitive symptoms were strongly associated with total quality of life (F = 32.5) and emotional (F = 20.5), social (F = 25.0), and school (F = 38.4) functioning while preinjury somatic symptoms and 5P risk score were significantly linked with PedsQL-4.0 total and physical subscale scores.

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