Concussion, Migraine, and the Athletic Trainer

Abstract

PURPOSE: Sport-related concussions and migraine are both national healthcare concerns that cost billions of dollars in economic burden annually in the United States as well as cause hardship on the individual. More than 539,600 student-athletes in the United States will be directly affected by both comorbidities each year, and the health care providers that care for them will have to make decisions based on both conditions. How healthcare providers are educated on these two conditions, their attitudes in diagnosing and managing these conditions, and beliefs about their role has not been established (aim 1). Due to a common pathophysiology, pre-morbid migraine has been identified as a risk factor for worse outcomes after an individual sustains concussion. However, the impact of these conditions and prescribed medications on commonly used baseline assessments has not been identified (aims 2 and 3). This may have implications in student-athlete referral to other healthcare professionals, in interpretation of test results, and in management of post-injury cases. Many individuals diagnosed with migraine take daily preventative medication (e.g., topiramate); however, these medications have been identified to cause cognitive impairment but the deficit in the collegiate student athlete and on the baseline concussion assessment is unknown (aim 3). Since cognitive exams make up a large portion of the concussion baseline assessment, identifying any real or perceived deficits in these tests may also allow healthcare providers to make decisions for test interpretation for these individuals. PARTICIPANTS: For aim 1, certified athletic trainers from the National Athletic Trainers’ Association and targeted social media groups were recruited to take a novel electronic survey. A total of 576 individuals that completed more than 90% of the survey were included in the final analysis. Student-athletes participating in club and varsity sports at Temple University undergoing routine baseline concussion assessments were recruited to have their data included for aims 2 and 3 (non-migraine = 387, migraine = 33, missing migraine status = 137). METHODS: The survey for aim 1 consisted of 7 subgroups of questions: demographics, concussion, migraine, and comorbid knowledge and atttitudes and beliefs. Questions mainly consisted of true/false and likert-style questions. For aims 2 and 3, student-atheltes completed their routine annual concussion baseline assessment. This consisted of a health history questionnaire, symptom checklist, Hospital Anxiety and Depression Scale, cognitive assessments, postural control test, and vestibular/oculomotor exams. Indiviudals that self-reported a history of migraine were included in aim 3 for analysis of medication use. RESULTS: For aim 1, 61% of respondents had a masters degree and 40% worked in middle or high school athletics. Over 94% of respondents previously reported receiving concussion education, compared to only 40.5% for migraine education. Respondents were able to correctly identify an average of 74% of concussion signs and symptoms and 66% of migraine signs and symptoms. Collegiate and split positions were associated with more negative concussion attitudes and beliefs. A lack of previous concussion or migraine education was associated with more negative attitudes and beliefs. For each year clinically practicing, attitude and belief scores were slightly more positive (β = 0.03 – 0.70, p < 0.001). Females also generally had more positive attitudes and beliefs across outcomes (β = 1.09 – 2.61, p < 0.001). A total of 577 student-athletes were included in aims 2 and 3. Having migraine was associated with 2.36 more symptoms (p = 0.008) and a 5.20 higher severity score (p = 0.005). Migraine was also associated with a 5.58 higher odds of a slower reading time on the King-Devick (p < 0.01). From ImPACT, having migraine decreased visual memory composite by 9.97-points (p = 0.02) and visual motor composite score by 3.89-points (p = 0.07). Of the 33 student-athletes with migraine, 15 were taking a prescription medication, 3 were taking an over-the-counter medication or supplement, and 7 were taking both. None of the athletes were taking a daily preventative medicaton for migraine. The median Migraine Disability Assessment score was 4.5, indicating only little or no disability. The Brief Disability Questionniare showed no significant difference between those with and without migraine (Kruskall-Wallis (1) = 0.4, p = 0.50). Finally, there was high provider trust as measured with the modified Patient-Doctor Relationship Questionniare, and no significant difference between those with and without migraine (Kruskall-Wallis (1) = 1.59, p = 0.21). CONCLUSION: This was one of the first studies to identify athletic trainer knowledge, attitudes and beliefs surrounding concussion and migraine. Idenitfying groups with decreased atttitudes and beliefs can be used for targeted programming and ensuring these athletic trainers have support to increase knowledge and attitudes and beliefs for more positive patient outcomes. This study also determined that migraine affects some aspects of baseline concussion assesments. This can be used by clinicians during test interpretation for patient care. These student-athletes had low measures of disability and high levels of provider trust, key components for individuals with migraine to receive appropriate care. Concussion and migraine are significant healthcare concerns present in populations seen by athletic trainers. Future studies exploring post-concussion migraine effects and medication over the course of collegiate career should be considered. Adequate knowledge and positive attitudes and beliefs would be beneficial in ensuring appropriate medical care given to individuals experiencing these conditions.