Headache types and treatments (1/21/21 newsletter)

Jan 25

We would like to acknowledge our volunteers and leadership team members who wrote for this newsletter:

Writers: Will Altaweel, Malayka Gormally, Mack Hancock, Micale Hunt, Galen Moller, Ming Shen, Julian Szieff, Rainey Tilley, and Josh Wu.

Editors: Conor Gormally and Malayka Gormally.

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In The News

Concussion Alliance Co-founders will be interviewed

Wednesday, February 3, 7-8:30 pm PST: Brain Injury Radio host Kim Justus will interview Concussion Alliance Co-founders Malayka Gormally and Conor Gormally. Click on this link to access both the Live and On Demand show. Listeners can call in with questions.

Concussion Alliance's Neha Gupta featured in Real Woman magazine

Neha Gupta, the founder of Empower Orphans and the first American to win the International Children's Peace Prize (in 2014), is the newest member of our Professional Advisory Board. An interview with Gupta is the cover story for Real Woman magazine.

Education

Impaired visual-motor speed and nearpoint of convergence predict poor reading performance in students

Two specific concussion-induced vision problems predicted poor reading performance for students (ages 14-22 years) with sport or recreation-related concussion. Natalie Sherry et al. found a correlation between (reduced) visual-motor speed and (reduced) reading accuracy. They also found a correlation between a problem with nearpoint of convergence and reading rate. Nearpoint of convergence is “the distance from your eyes to where both eyes can focus without double vision.”

The authors note that symptoms did not predict reading accuracy or rate. The study, published in Applied Neuropsychology: Child, involved 70 students and concluded that problems in visual-motor speed and nearpoint of convergence are “predictive of academic reading performance” after sports or recreation-related concussion. The authors suggest that clinicians use this information to “better inform academic accommodations.”

Sports

Study finds that states with greater football participation were slower to pass concussion laws

A study conducted by Thomas Rotolo and Michael Lengefeld found that between 2007-2014, states with a higher percentage of high school football participation were slower to pass laws that increased return-to-play restrictions following a concussion. The study, published in Social Science and Medicine, showed that every 1% increase in football participation correlated with a 21.4% increase in the risk that a state delayed adopting a concussion law. This relationship was statistically significant, even when controlling for other variables such as a state’s Republican representation, number of physicians, and women’s labor participation.

Given that social and cultural norms associated with football (e.g., toughness, aggression) may be more pervasive in states with greater football participation, the authors take the findings to suggest that these states may have resisted the adoption of laws that were perceived to threaten these norms. However, the specific people or groups that resisted these laws’ implementation remains unclear.

Cannabis & Psychedelics

New psilocybin study for PTSD and concussion announced

In a press release, Lobe Sciences announced its collaboration with the University of Miami to conduct preclinical trials studying the potential treatment of mTBI (concussion) and PTSD with NAC (an antioxidant precursor) and psilocybin. Growing research is showing that psychedelic-assisted therapy can be useful in reducing symptoms for patients with PTSD.

Many mTBI patients, especially veterans and service members, experience PTSD and PTSD-like symptoms alongside their concussion symptoms. The need for effective treatment is becoming increasingly evident. This preclinical trial will use a rodent model to test for the safety and efficacy of this drug combination, though NAC has already proven to be a safe treatment for mTBI. Results from the animal trials are expected in 2021.

Diagnostics

Newly approved blood test for mild traumatic brain injury (concussion) shows promise for early clinical detection

According to an Abbott Laboratories press release, the FDA has approved the first blood test to test for acute mild traumatic brain injury (concussion). Designed by Abbott Laboratories in partnership with the U.S. Department of Defense, this test uses a blood sample to evaluate the levels of two proteins (GFAP and UCH-L1) after a “concussion or head trauma.” Research has demonstrated that these proteins are frequently elevated after a traumatic brain injury.

This tool will provide clinicians with “an objective tool” for an evaluation, as the two proteins “are tightly correlated” with brain injury, and the test results have a “95.8% sensitivity and greater than 99% negative predictive value.” A negative result will rule out the need for a CT scan, which exposes patients to radiation. A positive result will prompt a CT scan and “help clinicians evaluate whether someone has a TBI.” While not a definitive diagnostic tool for concussion, this test will be a valuable early screening device giving clinicians more information on their patients. Further research and clinical use will reveal the diagnostic value of both the test and these two biomarkers in detecting mild TBI.

Self-care

Self-care and treatments for post-concussion headaches

Our new page, Headaches After Concussion, describes five types of post-concussion (or post-traumatic) headaches and potential treatments, including self-care, for each type of headache. The article also discusses general self-management advice for patients with post-traumatic headaches and what types of healthcare providers to see for post-traumatic headaches.

Our Headaches: Advanced Page goes into more detail about specific treatment options, including self-care options. The article also explains the pathophysiology (disordered biological processes) of the different types of post-traumatic headaches.

Elizabeth Sandel, MD, Medical Director for Paradigm and author of Shaken Brain, reviewed both headache pages for content accuracy.

Therapies Currently Available

Some concussion patients may have atypical dependence on visual and vestibular stimuli

A study conducted by Jaclyn B. Case et al. investigated persistent visual and vestibular impairments of postural control following a concussion. Visual and vestibular impairment are common symptoms among concussions and traumatic brain injuries. The study aimed to better-understand vestibular issues following concussion, an area that still requires further research.

Humans control their balance “based on a combination of movement and orientation cues from visual, vestibular, and proprioceptive systems.” In this study, the researchers unsettled (perturbed) “the participants’ visual, vestibular, and proprioceptive (physical) systems” by using specialized visual, audio, and physical stimulus. The study consisted of 3 groups of participants: a “sub-acute concussion” group (made up of patients between two weeks and six months post-injury who reported being asymptomatic), a “concussion history” group (over one year following a concussion), and a control group.

The results showed that the sub-acute concussion and concussion history groups responded more strongly to both the visual and vestibular stimulus than the control group. There was no difference between the groups regarding response to the proprioceptive stimulus. The authors hypothesize that the patients who responded more strongly to visual and vestibular stimuli may have an abnormal dependence on visual and vestibular feedback, suggesting that these are promising areas for targeted rehabilitation interventions in these kinds of concussion patients.

Therapies Being Researched

Integrated stress response inhibitor (ISRIB) shown to improve age-related memory problems in mice

New research published in the journal eLife sheds light on a drug, ISRIB, that could aid in slowing or even preventing age-related cognitive decline. Furthermore, a 2020 study showed that ISRIB, an integrated stress response inhibitor, improved memory after mild repetitive head trauma. These results overall indicate that ISRIB could eventually be a useful drug for TBI patients.

Researchers Krukowski et al. found that treatment with ISRIB reversed age-related damage on spatial memory, improved working and episodic memory, and led to several beneficial cellular effects. The brain activates an integrated stress response (ISR) during aging; ISRIB is a “drug-like” small molecule ISR inhibitor that “reverses ISR activation in the brain.”

The researchers compared behavioral and cellular effects of ISRIB in young and old mice. They found improvements in the old mice that restored their memory and cognition to levels “comparable to that of young mice.” Improvements in cognition (spatial, working, episodic memory) were accompanied by enhanced excitability of neurons and dendritic spine density, in addition to decreased age-related inflammatory tone.

Veterans and Service Members

Veterans sought for TMS study

After suffering a traumatic brain injury during his military service, veteran Dirk Harkins found a treatment he says helped save his life. Now, he wants fellow veterans to join a free pilot program called The Ohio Veterans NOW Project and try treatment with TMS. Transcranial magnetic stimulation (TMS) is a non-invasive procedure where an electromagnetic coil is placed on the scalp and delivers repetitive magnetic pulses to stimulate nerve cells in the brain. The treatment is painless, and veterans who have already joined the program are “coming in happy and refreshed, according to an article in The Times Leader.

Participants must be veterans of the U.S. Armed Forces, National Guard, or Reserves, and be residents of the State of Ohio. The project is looking for veterans “struggling with substance use disorders or mental health disorders" who are "willing to participate in the intensive program.” To learn more or to sign up, call 614-665-7905 or 614-293-4840. There is no cost to patients in the pilot program.

Mental Health

The relationship between PTSD and chronic inflammation

Post-traumatic stress disorder (PTSD) can occur along with traumatic brain injury (TBI). A Psychology Today article by Melanie Greenberg, PhD, examines the results of a 2015 systematic review and meta-analysis that compared inflammatory markers in patients with PTSD with a group of healthy controls. They discovered that PTSD is a mind-body disorder, not solely a mental health problem.

The authors of the systematic review (Ives Cavalcante Passos, MD et al., published in Lancet Psychiatry) observed that people with PTSD had higher concentrations of inflammatory cytokines. The abnormal amount of these cytokines lead to chronic systemic inflammation. Chronic inflammation can impair numerous health areas, including neuron creation, memory storage, and physical organs.

According to Dr. Greenberg, these findings suggest treatments for PTSD should address the physical disorders in conjunction with mental issues. She lists aerobic exercise, alternative medicine treatments, mindfulness, and cognitive-behavioral stress-management strategies as some of the valuable treatments that can help manage the stress and inflammation of PTSD. Dr. Greenberg stresses “to consult with a mental health professional for an evaluation” as untreated PTSD can pose a significant health risk.

Statistics

Physiological indicators of neurodegeneration linked with low sleep quality

A recent study conducted by the Uniformed Services University of Health Sciences found that poor sleep quality correlates with increased neurodegeneration biomarker concentrations and decreased executive function. In the article, published in SLEEP, the authors J. Kent Werner Jr. et al. discuss the necessity to explore pathological (unhealthy) sleep's relation to cognitive processes. They also investigated levels of neurofilament light (Nfl), tau, and amyloid-beta, biomarkers used to estimate injury severity of mTBIs and associated with the development of neurodegenerative diseases. Previous to this study, little research has assessed the correlation between these factors.

The researchers performed a retrospective analysis on a group of US military members and veterans with and without chronic mTBI. They used self-reported sleep quality and quantity measures from the participants and blood samples to measure neurodegeneration biomarker concentrations. The analysis also included several cognitive tests to evaluate executive function and memory.

Werner Jr. et al. found that Nfl levels were significantly higher for participants with mTBI who indicated poor sleep quality than those who reported good sleep. Participants with mTBI who were poor sleepers also had lower scores for some cognitive tests, such as categorical (verbal) fluency.

The authors briefly discuss the study's limitations, such as the small sample size, subjective sleep measures, and the lack of available data for sleep quality and quantity before the injury, which suggests that further research should seek to understand the generalizability of these findings. Regardless, the study demonstrates the need for future studies to assess both sleep in TBI studies and the relationship between sleep quality and neurodegeneration.

Youth

Should there be an evidence-based return to driving guideline for adolescents?

A study published in the Journal of Adolescent Health analyzed adolescents’ returns to driving after a concussion. Catherine C. McDonald, PhD, R.N., et al. note that, despite the possibility of cognitive and neurophysiological impairment after concussions, “there are no evidence-based guidelines for return to driving post-injury for adolescents.”

The study analyzed a sample of 332 adolescents, aged sixteen to nineteen, who had completed a questionnaire (including questions about driving), were diagnosed with a concussion within 28 days of injury, and were treated at a specialized concussion care clinic. Among the total sample, very few respondents had returned to exercise (15.4%), sport (6.0%), or were “provider-recommended to return to full school days'' (8.9%). Despite these percentages, almost half (46.9%) of the adolescents had returned to driving, either reporting “driving with no changes” or “driving with changes.” The study suggests that a “gradual increase in driving may be justified” similar to the evidence-based gradual return to school, exercise, and sports guidelines.

Women's Health

Understanding traumatic brain injury in females: a review of the current literature and future directions

While traumatic brain injuries (TBI) impact all sexes and genders, preclinical or clinical studies often focus on male subjects, which has led to an incomplete understanding of TBI in females. A recent article in The Journal of Head Trauma Rehabilitation identifies current issues and challenges related to TBI research in females, providing several suggestions for future research to address these issues.

The authors, Eve M. Valera, PhD, et al., separate their review into three key TBI research areas that overlook females, despite evidence of sex-specific differences. First, rates and outcomes of TBIs differ by sex across the lifespan. Analyses that find higher rates of TBIs in males fail to consider differences between pediatric populations (where females have a lower incidence of TBI) and aging populations (where females over 65 years have the highest rates).

Second, most data collection on TBI "groups" has focused on males. Accordingly, there is limited research addressing intimate partner violence, which disproportionately impacts women. There is a lack of understanding of sex differences in the effects of female sports-related concussion. There is a limited understanding of military-related TBI on female veterans and military personnel.

Third, sex-specific biological and social factors affect TBI rates and recovery. Given females’ underrepresentation in TBI research, there is an incomplete understanding of the biological response to and recovery from TBI. The authors conclude by providing suggestions to address the issues and challenges they have outlined.

Culture

Less-lethal projectiles violated UN guidelines during the George Floyd protests

A letter to The New England Journal of Medicine concludes that less-lethal projectiles are not appropriate for crowd control, based on the kinds of injuries they caused during the George Floyd Protests in Minneapolis in 2020. Erika Kaske, B.S., Samuel Cramer, MD, PhD, et al. searched records from two large Minnesota hospital systems and found 89 people who sought medical evaluations between May 26 and June 15, 2020, for injuries from less-lethal weapons. 64% (57) of these patients had injuries from projectiles such as rubber bullets and bean bags. Alarmingly, 40% (23) of the projectile injuries were to the head, neck, or face, including 16 traumatic brain injuries.

United Nations guidelines dictate that less-lethal projectiles should only be aimed at extremities; aiming at the head, neck, or face is potentially unlawful. The researchers acknowledge that their results “represent only a single region in a worldwide protest,” and their sample is limited only to people who sought medical attention for their injuries. Nonetheless, their findings show that, under current practices, projectiles can cause severe injuries and are not appropriate for crowd control. Researcher Erika Kaske, in an interview with CBS Minnesota, said, “We hope we can work with public policy makers in Minnesota to prevent this from happening to our patients in the future.”