This week's lead article, Migraine medication may help with post-traumatic cervicogenic headache, is in the Therapies & Diagnostic Tools Under Research category.

In this newsletter: Opportunities, Education, Sports, Self Care, Therapies & Diagnostic Tools Under Research, Veterans, and CTE & Neurodegeneration Issues.

We appreciate the Concussion Alliance Interns and staff who created this edition:
Writers: Minhong Kim, Susan Klein, Aaron Banse, Nancy Cullen, and Malayka Gormally

Editors: Conor Gormally and Malayka Gormally

Do you find the Concussion Update helpful? If so, forward this to a friend and suggest they subscribe.

Opportunities

Thursday, February 23, 1 pm EST: a free webinar on concussion with Dr. Carmela Tartaglia, Cognitive Neurologist, presented by University Health Network of Toronto. The webinar addresses symptoms, risk factors for persistent concussion symptoms, and treatment and recovery, ending with a Q&A. Register in advance.

March 2, 8:15 pm EST: concussion diagnostic device company Oculogica is holding a Virtual Open House with founder Dr. Uzma Samadani, MD, Ph.D., and VP of commercial development to give an overview of their EyeBOX concussion diagnostic tool. Those curious about the diagnostic tool space may be interested in learning more about EyeBOX and can sign up for the free Open House here. Note: This announcement is not an endorsement of this product.

March 7, 6 pm EST: a free webinar, Anxiety, Depression and PTSD: Before and After Concussion, presented by Dr. Abe Snaiderman and hosted by the Canadian Concussion Center. Register in advance.

Female athletes wanted for a short online research survey. Researchers at Mount Sinai Icahn School of Medicine are working to understand menstrual cycle functioning in athletes who have experienced a sports-related concussion or orthopedic injury. Take the survey here.

Athlete participants wanted for a 1 hr Zoom interview with researchers at Simon Fraser University investigating sport-related concussion. Participants must have sustained a sport-related concussion in the past year. Contact Kyle Bergh, kyle_bergh@sfu.ca, 604-989-7887.

Education

New CATT Concussion Pathway for neurodivergent students and students with disabilities

Cattonline recently created a new Concussion Pathway for Neurodivergent Students and Students with Disabilities. Cattonline is the Concussion Awareness Training Tool (CATT), a resource for concussion education; they have pdf resources plus e-learning courses for different audiences. In particular, they have mapped out a CATT Concussion Pathway (in pdf format) that includes assessing for red flag signs, identifying concussion, when and where to seek medical care, initial recovery protocol, and mental health assessment during recovery. However, there are instances where the general framework is not applicable; there are two main differences between the original concussion pathway and the pathway for students with neurodivergence or disabilities. These differences relate to additional concussion symptoms and recommendations for support.

First, neurodivergent students and students with disabilities should not be left alone when a concussion is suspected. Once a student has been removed from activity, an individual (such as a staff member) with a close connection to the student should provide emotional support and help determine if there are red flags or concussion signs/symptoms outside of the student's baseline presentation. The second difference is that while the red flags are the same as the generic concussion pathway, there are four extra possible concussion signs/symptoms for these students:

cannot be comforted or excessive crying
lack of interest in preferred items/activities
listlessness or tiring easily
loss of ability to carry on with baseline skills (across any social, emotional, language, or physical development domains)

As is true in both pathways, an ambulance should be called immediately if any red flags signs or symptoms are identified. If no red flags are determined and there are no concussion signs and symptoms, the student should still limit activity for up to 48 hours before returning to play. If any signs/symptoms are found at that time or in the ensuing 48 hours, they should seek medical attention from a licensed medical professional. CATTonline was developed by the British Columbia Injury and Research Prevent Unit and BC Children's Hospital.

Sports

No adverse cognitive or behavioral changes over three seasons of NCAA soccer

A recent study published in Medicine & Science in Sports and Exercise compared preseason baseline testing results in male and female NCAA soccer athletes and a control group of non-contact athletes over three consecutive years. Jaclyn B Caccese et al. examined if playing soccer, as opposed to non-contact sports, impacted their cognitive and behavioral outcomes. Although soccer is known to expose some players to head impacts throughout the season, the study found few significant differences in outcomes between soccer players and non-contact athletes. The only differences skewed in favor of the soccer players: soccer athletes reported lower (better) scores for depression symptoms, global severity index (a general measure of cognitive problems), and post-concussion symptoms. These scores did not worsen during the three-year study period.

While concussions are still an issue, these results suggest that simply playing soccer will not affect your cognitive functioning. Unfortunately, the study did not examine long-term effects and only tested athletes during the preseason. The latter may have affected results, as it’s possible that cognitive functioning may vary throughout the year if players experience more impacts during the season. Still, the lack of change in symptoms across seasons is promising for the long-term health of players.

Self Care

Balance training – what it is, how to do it, and why you should

In an article from the Washington Post, Michele Stanten describes how balance training can significantly reduce the risk of falling, one of the most common causes of concussions, particularly for those 65 and older. “Balance training is a program of activities designed to improve your response to potential fall hazards,” advises Evie Burnet, the Director of the Center for Balance and Aging Studies at William & Mary. The programs that are most effective are the ones that combine exercises from strength training, such as lunges, squats, and other standing exercises that work on legs, back, and abdominal muscles (all of which are important for stability), with functional exercises, which are exercises that imitate everyday activities.

However, there’s no one specific program that has to be followed; some senior centers or YMCAs might offer programs, but individuals can easily build programs for themselves through multiple different exercises. One expert states that walking in zigzags, changing the level of one’s speed throughout a single walk, or just frequent direction changes can help improve one’s balance. Some studies have found that yoga, tai chi, or even dancing (with or without a partner) all help as well.

Ms. Stanten ends the article with three exercise suggestions that should each be done 2-3 times a day: around-the-clock, tightrope walking, and going up.

Around-the-clock. We are unsure if Ms. Stanten has fully described this exercise, and there are different versions of the clock balance exercise. Ms. Stanten describes standing still and shifting your body (from the hips) forward (as if to the 12 o’clock position) and then back to center, and then proceeding to the next positions of a clock). We found one video by a physical therapist demonstrating a forward step with one foot (with a weight shift) and then back to position, then to the side, etc., around the body in a clock formation. Another video demonstrates keeping your weight on one leg the entire time and tapping the points of a clock with the other leg.
Tightrope Walking is what it sounds like, without the actual tightrope: imagine (or even use a string or other marker) a line on the ground. Then, walk the line while placing one foot directly in front of the other without touching each other. Do this without looking at the floor but instead at a point somewhere in front of you. Do this exercise near a wall so that if you feel unsteady, you can place a finger on the wall to help.
Going Up is an exercise that starts with sitting on a chair with your feet on the floor. Start to stand up from the chair without the help of your hands, but only start to stand up a little before sitting back down. Progressively stand up more each time until you fully stand up from the chair.

Therapies & Diagnostic Tools Under Research

Migraine medication may help with post-traumatic cervicogenic headache

Zaw, Zaw, and Torres recently published three case reports in Cureus of adult women diagnosed with cervicogenic headache secondary to trauma who were treated with a limited trial of a CGRP antagonist, rimegepant. All three women reported that their 7-10/10 daily head and neck pain was reduced to 4-5/10 severity for several hours after taking a dose of rimegepant but that headaches did not decrease in frequency and severity after this medication trial.

Rimegant is a CGRP antagonist, a class of drugs for “the prevention and acute treatment of migraines,” which works by blocking calcitonin gene-related peptide (CGRP). The authors concluded that if CGRP increases following cervical spine trauma, as reported in animal research, a CGRP antagonist such as rimegepant might be part of a treatment approach to headache and neck pain after whiplash injury.

Note: Although the study doesn’t address concussion, all three women developed a cervicogenic headache after sustaining a whiplash injury in a motor vehicle accident. Post-traumatic headache (PTH) is “one of the most common sequelae of mild traumatic brain injury.” See our resource, Headaches After Concussion.

While there are several interesting links between the mechanisms of migraine and brain changes following head injuries, there are some important things to keep in mind before patients with whiplash injury might consider a trial of rimegepant. Zaw and colleagues point out that their diagnosis of cervicogenic headache was made on clinical grounds and was neither randomized nor blinded. A 2019 review of how difficult it is to assess the effectiveness of therapies specifically for cervicogenic headache echoes their cautions. Secondly, Zaw’s group was careful to exclude treatable causes of this type of headache, such as aneurysm or vertebral dissection (a tear in an artery of the neck); this would be vital before beginning medication therapy. Finally, rimegepant and CGRP antagonists are new therapies. Side effects, such as nausea and allergy, and medication interactions for CGRP antagonists need to be considered.

Understanding the targets of the CGRP antagonists in head injury is also far from clear, so we need to consider what Olesen and Ashina have said about expanding their uses for other headache types. Finally, using a CGRP antagonist to rescue a severe headache (immediate treatment) differs from using a formulation that will suppress headache; no one seems to understand yet how that could be achieved for post-traumatic headache. These medications are generating a lot of interest, so stay tuned.

Veterans

Free, no-wait emergency health care for veterans in suicidal crisis

Veterans in a suicidal crisis no longer have to endure long waitlists at the VA; they can now go to "any VA or non-VA health care facility for free emergency health care," according to a VA announcement in January. Veterans "do not need to be enrolled with the VA system" to access this program, which includes inpatient and outpatient services. The VA estimates this new program increases access to the approximately 9 million veterans not enrolled in the VA.

The most recent VA report found that 6,146 veterans died by suicide in 2020. "PTSD, mild traumatic brain injury, insomnia, that led to a lot of suicidal ideations, so I've been there, I've been in the dark times," said veteran Damon Friedman in an article about the new program in ABC Action News.

This new free health care covers up to 30 days in an inpatient or residential care facility and up to 90 days of outpatient care. The VA will also "provide, pay for, or reimburse" transportation to inpatient or outpatient care and follow-up care (and appropriate referrals) after inpatient or outpatient care. Eligibility requirements are listed here.

CTE & Neurodegeneration Issues

91.7% of former NFL players studied have been diagnosed with CTE

Researchers from the Boston University CTE Center have diagnosed CTE in 91.7% of former NFL players studied. Out of 376 former players, 345 were found to have CTE.

CTE, which is caused in part by repeated traumatic brain injury, can develop in professional football players, who may sustain “hundreds or thousands of head impacts over the course of many years playing contact sports.”

However, researchers from the CTE center stress that this high rate of CTE diagnosis in former NFL players “should not be interpreted to suggest that 91.7 percent of all current and former NFL players have CTE.” This is because of the inherent selection bias in brain bank samples: football players experiencing symptoms of CTE may “be more likely to register for the brain bank than those not sensing problems.”

Dr. Ann McKee, the director of the Boston University CTE Center who has spearheaded research on CTE, concludes that “while the most tragic outcomes in individuals with CTE grab headlines, we want to remind people at risk for CTE that those experiences are in the minority.”