Migraine with Aura or Sports-Related Concussion : Case Report, Pathophysiology, and Multidisciplinary Approach to Management

Migraine is a collection of perplexing neurological conditions in which the brain and its associated tissues have been implicated as major players during an attack. Once considered exclusively a disorder of blood vessels, compelling evidence has led to the realization that migraine represents a highly choreographed interaction between major inputs from both the peripheral and central nervous systems, with the trigeminovascular system and the cerebral cortex among the main players. Advances in in vivo and in vitro technologies have informed us about the significance to migraine of events such as cortical spreading depression and activation of the trigeminovascular system and its constituent neuropeptides, as well as about the importance of neuronal and glial ion channels and transporters that contribute to the putative cortical excitatory/inhibitory imbalance that renders migraineurs susceptible to an attack. This review focuses on emerging concepts that drive the science of migraine in both a mechanistic direction and a therapeutic direction.

Management of dizziness and balance dysfunction is a major challenge after concussion. The purpose of this study was to examine the effect of vestibular rehabilitation in reducing dizziness and to improve gait and balance function in people after concussion. A retrospective chart review of 114 patients (67 children aged 18 years and younger [mean, 16 years; range, 8-18 years]; 47 adults older than 18 years [mean, 41 years; range, 19-73 years]) referred for vestibular rehabilitation after concussion was performed. At the time of initial evaluation and discharge, recordings were made of outcome measures of self-report (eg, dizziness severity, Activities-specific Balance Confidence Scale, and Dizziness Handicap Inventory) and gait and balance performance (eg, Dynamic Gait Index, gait speed, and the Sensory Organization Test). A mixed-factor repeated-measures analysis of variance was used to test whether there was an effect of vestibular rehabilitation therapy and age on the outcome measures. The median length of time between concussion and initial evaluation was 61 days. Of the 114 patients who were referred, 84 returned for at least 1 visit. In these patients, improvements were observed in all self-report, gait, and balance performance measures at the time of discharge (P < .05). Children improved by a greater amount in dizziness severity (P = .005) and conditions 1 (eyes open, fixed support) and 2 (eyes closed, fixed support) of the Sensory Organization Test (P < .025). Vestibular rehabilitation may reduce dizziness and improve gait and balance function after concussion. For most measures, the improvement did not depend on age, indicating that vestibular rehabilitation may equally benefit both children and adults. Vestibular rehabilitation should be considered in the management of individuals post concussion who have dizziness and gait and balance dysfunction that do not resolve with rest.

Recognizing and managing the effects of cerebral concussion is very challenging, given the discrete symptomatology. Most individuals with sports-related concussion will not score below 15 on the Glasgow Coma Scale, but will present with rapid onset of short-lived neurological impairment, demonstrating no structural changes on traditional magnetic resonance imaging (MRI) and computed tomography (CT) scans. The return-to-play decision is one of the most difficult responsibilities facing the physician, and so far this decision has been primarily based on neurological examination, symptom checklists, and neuropsychological (NP) testing. Diffusion tensor imaging (DTI) may be a more objective tool to assess the severity and recovery of function after concussion. We assessed white matter (WM) fiber tract integrity in varsity level college athletes with sports-related concussion without loss of consciousness, who experienced protracted symptoms for at least 1 month after injury. Evaluation of fractional anisotropy (FA) and mean diffusivity (MD) of the WM skeleton using tract-based spatial statistics (TBSS) revealed a large cluster of significantly increased MD for concussed subjects in several WM fiber tracts in the left hemisphere, including parts of the inferior/superior longitudinal and fronto-occipital fasciculi, the retrolenticular part of the internal capsule, and posterior thalamic and acoustic radiations. Qualitative comparison of average FA and MD suggests that with increasing level of injury severity (ranging from sports-related concussion to severe traumatic brain injury), MD might be more sensitive at detecting mild injury, whereas FA captures more severe injuries. In conclusion, the TBSS analysis used to evaluate diffuse axonal injury of the WM skeleton seems sensitive enough to detect structural changes in sports-related concussion.