Concussion in Women and Girls
A growing body of evidence suggests that women are at higher risk for concussions and experience a greater number and longer duration of concussion symptoms compared to men. Despite these findings, the sport, academic, military, and medical communities do not have any female-specific medical guidelines, according to recent research.
Research on traumatic brain injury (TBI), including concussion, has been dominated by studies on male contact sport athletes and military service members. This disparity has not only left a gap in understanding how TBI affects women but has also relegated entire populations of TBI survivors to the margins. Survivors of intimate partner violence, most commonly women, have been particularly underrepresented in the discussion surrounding TBI. An increasing number of researchers, clinicians, and social workers are insisting that more research into female brain injury is needed. It is vital to increase our understanding of sex differences in TBI and to support female recovery from brain injury.
Note: The majority of research is based on the binary (female/male/intersex) understanding of biological sex. We acknowledge that not all women concussion patients are biologically female and that not all biologically female concussion patients are women.
Contents
Outcomes, Symptoms & Diagnosis of Concussion in Women
Pathophysiology Differences of Women with Concussions
TBI caused by Intimate Partner Violence
Outcomes, Symptoms & Diagnosis of Concussion in Women
Dr. Tracey Covassin talks about her research on concussion in women’s sports & her hopes for the future.
Chris D’ Lauro, a neuroscientist, said it best on Twitter: “A protocol is not designed for all athletes when it includes only 20% female data”. Females are significantly under-represented in the studies that are guiding current clinical care for sport-related concussion. When looking at the most influential consensus statements on treating concussions, the samples were over 80.1% male and 40.4% of the studies included no female participants at all. Recent research suggests that concussed female athletes have greater neurocognitive impairments, more total self-reported symptoms, and longer recovery times than their male counterparts. A review of 25 studies on sports-related concussions showed that females are not only more susceptible to concussion, but also experience more severe concussion symptoms than males.
Differences in Symptoms: Cognitive, Physical, and Emotional
Figure by Rachel S. Johnson, PhD, ATC
Other research has discovered that females experience post-concussion syndrome differently than males. They have more cognitive symptoms and also experience more symptoms relating to migraines and dizziness – as well as facing more emotional dysregulation and a higher risk for reduced health-related quality of life. This study found that females were 1.5 times more likely to experience neurocognitive impairment than males.
Executive functioning of the brain plays a role in everyday life. Research has shown that females with concussion face greater alterations to executive function and long-term cognitive impairments. Executive function and self-regulation skills are the mental processes that enable us to plan, focus attention, remember, and juggle multiple tasks. Some examples of a deficit in this area may include difficulty carrying out a sequence of steps to complete a task (i.e. cooking multiple dishes at once), difficulty thinking ahead, or finding it hard to concentrate on a single task or focus while in a complex environment.
Resources to Find Help
For cognitive issues, visit our page on Cognitive Rehabilitation. For emotional issues, check out our pages on Mental Health, Cognitive Behavioral Therapy, The Invisible Injury, and Emotional Wellness.
Societal Factors influencing Poorer Outcomes for Women
While it is becoming increasingly clear that concussions may be experienced differently in females than males, there are many influences that lead to worse outcomes, including societal factors. According to a 2020 study, women were less likely than men to be referred from a hospital to a study center (12% vs. 16%) and waited longer to get a CT scan. Similarly, a study on pediatric female concussion found that girls were evaluated by a specialty care provider later (15 days vs. 9 days) than boys. Girls also took longer to recover in 5 different categories: returning to school without accommodations, returning to noncontact exercise, returning to full sport activity, recovery of neurocognitive function on computerized testing, and clinical recovery of vision and vestibular deficits. These differences in recovery vanished when girls were seen by specialty care within the first 7 days.
Furthermore, differences in outcomes could also stem from female athletes’ unequal access to athletic trainers and quick medical care in their sports. Evidence shows when given equal access to immediate care, women and men with sports concussions have almost identical recovery times.
Another influential factor is that most, if not all, sports concussion protocols are based on male data, which puts females at an even greater risk of serious injury. One study pointed out that high school age boys typically had their symptoms go away by day 7, whereas high school age girls' symptoms prolonged 14 to 28 days later. Current protocols vary by state, but a study found there was a 71% probability of returning to high school sports after just 7-9 days. These return-to-play protocols are putting players, especially girls, back in the game before they may have even had the chance to fully recover. This goes to show that because of what is known about the difference in recovery time, return-to-play protocols may need to be different for girls than boys.
Occupational Performance Problems
Figure provided by Dr. Nick Reed, Department of Occupational Science & Occupational Therapy, University of Toronto. This figure shows occupational performance problems female youth participants reported after a concussion.
A study published in the British Journal of Occupational Therapy is one of the first to look at occupational performance as an indicator of recovery for youth with concussion. It was discovered that following concussion, there was a wide variety of performance issues experienced by female youth – and this expanded to more than just difficulty returning to school or sports. 61% of female youth reported issues with leisure activities after a concussion such as crafts, playing a musical instrument, cooking, and going to the mall with friends. 10% reported issues with self-care after a concussion which included eating well, managing energy, and sleeping. This shows that rehabilitation after a concussion is about more than just decreasing headaches and returning to sports or school work.
Pathophysiology Differences of Women with Concussions
Axons
One difference between male and female anatomy is that female axons are smaller and have fewer microtubules, when compared to males. Microtubules help provide structure and shape to the axons. The study that found this difference between male and female axons was conducted on both rat and human neuronal cells. The researchers believe that during everyday activities, the differences in the axons has no impact. However, when the same force is applied to male and female brains, the female axons are more likely to break. The researchers believe that the breakage of microtubules may be what leads to loss of consciousness (when the concussion initially happens) and dizziness.
The left image shows the axons and microtubules of a female rat. The right image shows the axons and microtubules of a male rat.
Hormones
Hormonal differences might be another reason why females and males experience concussions differently. An article from the University of Rochester talks about how the menstrual cycle can influence concussion outcomes. The researchers focused on the premenstrual phase of a women’s period. During the approximately two weeks before menstruation, levels of progesterone are naturally high. If a concussion occurs during the premenstrual period there is a drop in progesterone that might contribute to or worsen concussion symptoms. Progesterone is known to have a calming effect, however after a concussion the production of progesterone slows. This slowing of hormone production is thought to lead to increased symptoms through the “Withdrawal hypothesis” coined by Dr. Jeffery Bazarian.
Menstrual Cycle
This alteration in hormones due to a concussion can also lead to other complications with the woman’s natural menstrual cycle. It was reported in a study that after a concussion, there is an increase in irregular periods, either less than 21 days or more than 35 days between periods. These menstrual irregularities can be tied to several disruptions caused by the concussion. One is the disruption of the neuroendocrine system through disruption of the hypothalamic-pituitary-ovarian axis which governs the menstrual cycle. Another disruption may be related to hypopituitarism, which is when your pituitary gland fails to produce or doesn’t produce enough of a certain hormone. If you are experiencing an alteration to your menstrual cycle, it is recommended that you seek out proper medical care. Disruption of the menstrual cycle could potentially lead to other health conditions.
See our page on Hormone Therapy for more information.
Neck Strength
The difference in neck strength between men and women may cause concussions to impact women differently than men. Males, in general, have greater neck muscle mass compared to females. In a study, males had 17.5% greater neck girth compared to females. Among the potential concussion prevention paradigms, increased neck muscle strength and/or pre-activation are widely believed to contribute to reductions in concussive events. (Pre-activation is the stretching or warming up of a particular muscle group prior to activity.) Not only this but it was found that female players’ necks are 47% weaker when compared to males. It is believed that increasing female neck strength can help reduce the severity of the concussion. It makes sense that a stronger, wider neck would be able to reduce head movement after an impact and thus lessening the forces on the brain. However, neck strength and girth are not the only influencers on female concussions.
TBI caused by Intimate Partner Violence
A conservative estimate is that 20 million women in the U.S. are affected by TBI from intimate partner violence. This number far exceeds the number of TBIs among Iraq and Afghanistan Veterans and National Football League players combined. However, according to Jonathan Lifshitz, “Health-care professionals across disciplines have rarely, if ever, considered domestic violence and intimate partner violence as a cause for TBI.”
Survivors of physical abuse have a chance to rebuild their lives with the help of Barrow Neurological Institute: a brain injury clinic in Phoenix, Arizona.
A 2015 report on traumatic brain injury (TBI) by the Centers for Disease Control and Prevention, titled “Traumatic Brain Injury in the United States: Epidemiology and Rehabilitation,” had no mention of domestic violence. Since TBIs are not widely considered a domestic violence issue, clinicians are often unprepared for disclosures of domestic violence and may attribute survivors’ concussion-like symptoms to mental illness or trauma from abuse. Many of the organizations aimed at helping survivors of domestic violence lack awareness of TBI. They often miss concussion symptoms in their clients and fail to accommodate their TBI-specific needs.
Even though there are decades of evidence that single and repetitive TBIs are a common consequence of IPV, there has been minimal research addressing outcomes from these injuries. It is important that the potential role of TBI-related cognitive impairments be considered when building support structures for survivors of intimate partner violence, as these impairments may be an additional barrier to escaping violent situations.
There is a strong relationship between IPV-related brain injuries and poor cognitive, psychological, behavioral, and overall health – as well as harm to functional and structural neural connectivity. Reports have indicated that up to 94% of injuries women sustain from abuse are to the neck and head. In a sample of women who had experienced at least one instance of physical partner violence, 74% sustained at least one IPV-related brain injury and 51% had a history of repetitive brain injuries. Women with IPV-related TBI with ongoing symptoms were reported to be nearly six times as likely to experience probable IPV-related PTSD as well as anxiety, depression, and fatigue.
Dr. Eve Valera has been a leader in the field of studying how survivors of intimate partner violence have been affected by traumatic brain injuries. She has published multiple IPV & TBI-related studies on topics such as white matter, neuro mechanistic trauma, strangulation, childhood trauma, increased incidence of partner-related TBI during the Covid-19 pandemic, as well as studies on the prevalence of brain injury in survivors. She has also greatly contributed to research that addresses the need to fill the gap in knowledge for practitioners, decision-policy makers, and women who may be affected.
For more information, check out our Partner-Inflicted Brain Injuries page.
What can I do?
Friends, shelter workers, and medical providers may be able to offer help by learning the warning signs of abuse. This includes listening, believing the victim, validating their feelings, creating a safety plan, and offering specific support. Doctors may consider incorporating intimate partner violence screenings into their medical examinations. Hotlines are available such as the National Domestic Violence Hotline.
Women in College
Research revealed that concussions are more than twice as common among college students as formerly believed. Concussions in college are also significantly more likely to occur outside of sports. Following the pattern of other research, this study concluded that incidence is higher among college females than college males. Among collegiate athletes in a study on D1 athletes, women exhibited greater symptom severity in the initial 3 days after injury compared to men. The same study found that women displayed more physical, somatic, and emotional symptoms than men. It was concluded that 32.6% of female collegiate athletes experienced symptoms for more than 2 weeks and over 23% continued having concussion symptoms for 3 or more weeks.
Mental Health Considerations for Women
Major depression, which disproportionately affects women in the general population, is considered one of the most common psychiatric disorders following TBI. On average, women report more depressive symptoms and perceived stress following TBI compared to men. A 2020 study found evidence that women actually experienced more severe post-concussion symptoms, depression, anxiety, and PTSD than men after concussion. Recent studies suggest that rates of common mental health disorders have increased in women and remained steady in men in the last decades, with younger women especially at risk.
The relationship between concussion and mental health is complex and multi-directional. History of mental health problems is a risk factor for poor outcomes after concussion and those with previously diagnosed mental disorders are at increased risk of concussion.
Women are 40% more likely to report nervous-anxious symptoms, which were shown to impede recovery. In a study exploring childhood TBI, including concussion, and its effect later in life, females were also significantly more likely to report a history of internalizing behaviors, including major depressive disorder and anxiety. This study of the history of internalizing behaviors points to the idea that childhood concussion may be associated with psychosocial issues as an adult. Awareness of risk factors for internalizing behaviors, such as being a female with a past concussion, can help with early diagnosis of mental health issues, intervention, and ensuring healthcare providers do not overlook symptoms.
Women with a concussion may face an altered sense of self, difficulty adjusting to a new identity post-injury, issues with loss of control, isolation, and even the added pressure to “pass as normal” in fear of being stigmatized. Concussion can cause uncertainty in one’s life, leaving women feeling alone, vulnerable, and insecure – which can lead to worsened mental health. These findings demonstrate that mental health is a critical issue for women with concussion; an accurate diagnosis is critical because treatment of mental health issues is essential for proper recovery.
Dr. Elizabeth Sandel states in a blog post that “Providers, patients, parents, and young people must understand the strong connection between traumatic brain injury (TBI) and mental health disorders. Screening for these disorders should be a part of healthcare encounters for patients with concussions.”
Check out our pages on Mental Health, The Invisible Injury, and Emotional Wellness for more information & resources to assist in recovery.
The Burden of Caretaking
One of the greatest burdens caretakers face is the lack of education on brain injuries such as concussion, persistent post-concussion symptoms (post-concussion syndrome) or chronic mTBI (which military service members are often diagnosed with). A study quotes a TBI caretaker, saying that “ ‘A lot of this stuff seems to be hidden, and you wouldn’t know about it unless you have someone who is in that field who can tell you what supports are out there that you can take advantage of...’.” In order to help alleviate some stress that encompasses caretaking for concussion, resources like Concussion Alliance can help to keep the caretakers up to date with current medical treatments. But not only is there a lack of resources for treatment, there is also a general lack of knowledge on how symptoms for these injuries present in different age groups.
Babies and Toddlers
During this period of development, symptoms of concussion can be easily confused with typical actions and reactions of babies and toddlers. Babies and toddlers are also unable to verbally express what they are feeling. All of this makes identifying a concussion for this age to be difficult. These symptoms might present in a form parents might not expect, such as;
Not being able to sleep through the night when previously able to
Regression in potty training when there wasn’t an issue before
Spending more time in their parents’ arms than normal
Asking for a stuffed animal or pacifier more than usual
Knowing that children being more fussy than normal can be a symptom of concussion is important. This information also helps a parent know when to contact the child’s pediatrician, and helps to ensure babies and toddlers receive proper care. A University of Montreal press release discusses a new observational tool that helps parents and clinicians recognize a concussion in this age group.
Young Children and Adolescents
Even with small changes in the level of stress within the family, a difference develops between the way a child reports their symptoms and the way a parent describes their child’s symptoms. Since the parent tends to be the advocate for the child's ailments, it is critical for the parent to listen to their child and to make sure they are on the same page. If there is a difference between what the child is telling the parent, and what the parent tells the physician, this can cause a disconnect. This disconnect may impact concussion diagnosis and management and possibly extend the recovery time for the child, potentially leaving the child with uncomfortable symptoms they must deal with in everyday life.
As a parent, your child may be experiencing symptoms that may not come across as concussion symptoms at first. Research shows that youth who experience concussion are at an increased risk for behavioral and mood disorders as well as psychiatric comorbidities like anxiety and depression.
Family stress as a whole can impact parents’ perception of their child’s emotional function, regardless of post-concussive symptom severity. Family stress can also impact the recovery period of the child. Overparenting can cause a delay in their child’s recovery and an increase in emotional distress. Overparenting is defined in this article as overly protective or involved.
Impact of Parent Time
As a caretaker, lots of planning and travel can be involved with caring for a child with a concussion. Children may have to leave school early until cleared by their doctor since symptoms such as concentration problems and light sensitivity can be problematic post concussion. Not only this, but doctor appointments can be far away from where one might live. Further, both the time spent with transportation and potential costliness of specialists not covered by insurance can cause financial strain.
Taking Care of an Aging Parent
Most of the research on the burden of caretaking looks at caretaking for traumatic brain injuries (TBI) that are moderate or severe, not mild traumatic brain injuries (concussions). However, the challenges that caretakers face can overlap, regardless of the severity of the brain injury. A study emphasizes the stress placed on the caretaker when another person was not available to provide relief to allow them to leave their homes. This can impact the caregivers well-being. According to previous research, the caregiver's well-being affects both their capacity and willingness to care for the injured person; and thus impacts the overall quality of life for both the person with TBI and the remaining family members.
Concussion Alliance’s treatments page is a great resource to educate caretakers on the different resources that could help a loved one struggling to recover from a concussion. Along with the treatments page, the ‘How to advocate for yourself in Dr appointments’ section later in this webpage can be helpful in ensuring that you or your child is heard and treated properly at these medical appointments.
What to do to help
Try to make a safe and encouraging space for the child or aging parent to be open about discussing symptoms, and show them you’re listening when they tell you what they are feeling.
Resources
How to Advocate for yourself in Doctor’s Appointments
“Medical Gaslighting” is a term that describes situations where medical professionals inappropriately dismiss patients’ symptoms or complaints as minor, insignificant, or psychologically-driven, leaving patients frustrated and often having not received the care they came in for. A typical example of this gaslighting is a doctor attributing women’s symptoms to psychological issues rather than treating women for physical health concerns. One study “found that women are twice as likely as men to be diagnosed with a mental illness when their symptoms are actually consistent with heart disease.” Because of this frustrating possibility of misdiagnosis, it is important to know how to advocate for yourself in appointments.
Find a Doctor you can trust- go doctor shopping. This can be through reaching out to people you trust about doctors in your area or reading credible reviews online. Patients who trust their doctor are in turn more likely to follow their treatment plan.
Come prepared with your information & research. One online source from Dr. Elizabeth Sandel, has a self-report guide to fill out. This allows for you to clearly communicate your or your child’s symptoms with the clinician.
Have a friend, family member, or patient advocate come with you. Unfortunately, doctors can dismiss symptoms coming from the patient. However, having another person who is not experiencing concussion advocating for your symptoms can help the clinician to see it isn’t from previous undiagnosed medical conditions or, worse, psychosomatic disorder or malingering.
Bring a list of questions with you and take notes during the appointment. Having specific questions written down can help keep you on track within the appointment. Bringing a notepad and pen can be helpful. Receiving a lot of information can be stressful, especially if it concerns something you may not have heard of before.
Push back if you have concerns — don’t settle for treatment you aren’t comfortable with. If you are not noticing a difference after multiple doctor visits, it is okay to say something! The treatments for you might be different than others you know with concussions; that is okay. Every person and concussion is different.
Confirm the next steps with your provider. Make sure to understand what your provider is saying before leaving the office. Some specialists may also require scans from previous visits, so make sure that the clinician knows to send over any scans. Along with making sure that you receive a summary at the end of the visit, you can tell other providers what has and hasn’t been working.
Consider switching providers if you feel unheard or unsupported. As a patient, you have the right to seek care from more than one provider and get a second opinion.
U.S. Department of Veteran Affairs
In 2015, women were officially allowed to serve in all military positions – even combat roles. Now, an increasing number of women are serving in the US Army, Air Force, Navy, and Marine Corps. Even so, most military research is male-focused and includes a very low number of females. Data from studies that have been done show that women veterans are more likely to experience depression, PTSD, alcohol use disorder, and a higher number of post-concussion symptoms. Female veterans with TBI were also more likely to have symptoms of nausea, changes in sleep & appetite, and fatigue.
The U.S. Department of Veteran Affairs (VA) is an integrated healthcare system that offers mental health services, women’s health services, and social work services to Veterans. The VA also provides resources for survivors of intimate partner violence.
Check the VA’s page on Women’s Health Services for more information. You may also want to visit our page on Concussions among Service Members & Veterans.
Patient Advocates & Care Coordinators
For people with persistent post concussion symptoms, finding the care they need can be a huge burden. Patient advocates and care coordinators are medical staff who are tasked with supporting patients. They work to help patients navigate the healthcare system, make sure they see the right specialists at the right time, help set up treatment plans, and advocate for health needs. If this seems like it would be useful to you, contact your local healthcare facility and ask to speak with someone about adding this role to your healthcare team.
Support Groups
For more information on support groups, visit our page on online support. Furthermore, you may be able to find other local or virtual support groups by searching online or on social media platforms like Facebook.
Stories of Women like You
To hear stories about other women who may be experiencing similar difficulties after a concussion, visit the Concussion Story Wall.
Initiatives in Female Brain Injury Research
The Boston University CTE Center is currently recruiting professional female soccer players 40 years and over for its “Soccer, Head Impacts and Neurological Effects (SHINE)” Study. SHINE is the first all-female study dedicated to understanding chronic traumatic encephalopathy (CTE). Phone #: 617-358-6545 Email: phelps@bu.edu
The Mount Sinai Health System is recruiting participants 18 - 45 years of age for a study assessing the relationship between menstrual cycle functioning & sports-related injuries! Click here for more information and to access a brief survey.
Related Blog Posts
According to a study done by Moran et al., hormonal contraceptives do not appear to influence neurocognition and oculomotor baseline assessment measures for sport-related concussion (SRC).