Headaches in Ex-Football Players Linked to Brain Injury

Pauline Anderson

April 27, 2015

WASHINGTON, DC — A new study shows that retired National Football League (NFL) players experience more headaches than the general population and suggests their headache and concussion history are associated with traumatic brain injury (TBI).

As well, almost all retired players in this small study had a history of depression or anxiety.

But perhaps "most striking" finding among ex-athletes in the study is that that they don't have access to health coverage, according to Frank Conidi, DO, Florida Center for Headache and Sports Neurology, Port St Lucie.

"Most did not have insurance," said Dr Conidi, who has offered to follow the players at no charge until they obtain insurance or have access to care through the NFL concussion lawsuit settlement.

The findings were presented here at the American Academy of Neurology (AAN) 67th Annual Meeting.

Timely Settlement

The presentation here was on the same day a federal judge approved a settlement to resolve the concussion lawsuit between the NFL and thousands of former players. The agreement will cost the NFL an estimated $900 million, if not more.

The current study included eight retired players, although the researchers have now looked at some 20 players. The participants were relatively young (mean age, 37.13 years; range, 30 to 43 years).

The athletes had played in the NFL for 2 to 9 years, with the average being 4.63 years. According to Dr Conidi, this is a typical career run for a professional football player.

These athletes reported an average of 7.25 concussions over their lifetime, with 15 being the maximum.

The players were tested over 2 days to prevent fatigue. On the first day, the participants underwent comprehensive neurologic testing, were rated on the clinical dementia rating (CDR) scale, and then had diffusion tensor imaging (DTI) MRI.

On the CDR, a score of 0 indicates no dementia, 0.5 is questionable, 1 is mild, 2 is moderate, and 3 is severe dementia. Researchers used a computer algorithm to obtain an average score.

On the second day, the players completed 5 hours of formal neuropsychological testing and psychological screening with the Mini-Mental Status Examination (MMSE) and Minnesota Multiphasic Personality Inventory (MMPI).

The researchers found that all players had normal results on neurologic examination. There was no indication of amyotrophic lateral sclerosis (ALS) or Parkinson's disease among the players, noted Dr Conidi.

The mean score on the CDR scale was 0.69, "which puts them in the questionable area," he said. The maximum was 1.0.

Headache Frequency

The athletes reported a mean of 19.4 headache days per month. Three players reported headaches on 30 days a month. About 38% met criteria for chronic migraine.

Participants experiencing headache had done so for about 8 years. Those with chronic migraine headaches had also had these headaches for approximately 8 years.

"None of the retired NFL players reported having any significant headache history prior to college," noted Dr Conidi.

Researchers found a correlation between the number of years played in NFL and the number of headache days, and between the number of concussions and the number of headache days, said Dr Conidi.

Seven of the eight patients were rated as having both depression and anxiety. This in itself could be a trigger for or a consequence of increased headache frequency, said Dr Conidi.

On neuropsychological testing, 63% of participants had abnormalities in attention and concentration, 50% had problems with learning and memory (executive function), and 38% had problems with spatial/perceptual function. All players who met criteria for chronic migraine also had significant abnormalities on measures of attention/concentration and learning/memory.

And those with a history of some form of daily headache had significant abnormalities on neuropsychological tests for attention/concentration and spatial/perceptual function. "This actually isn't surprising," commented Dr Conidi. "There are a number of studies in the literature showing that people with chronic headaches do have neurocognitive impairment."

"Impressive" Finding

Although the researchers didn't expect to find significant differences on DTI MRI, "lo and behold, there was a positive finding on the first patient we analyzed," which was "pretty impressive," said Dr Conidi.

He added that his center views a 2.5–standard deviation decrease from the norm as indicating a positive finding, whereas other centers use 2 standard deviations.

This finding was partially correlated to deficits in attention and concentration and in executive function in this patient, he said. This patient also had diffuse axonal injury on conventional MRI.

"We thought this was just a fluke until we got another patient back and that patient also had abnormalities" on DTI and conventional MRI.

Overall, three players had positive DTI scans, with the abnormalities mostly in the left and right corona. A fourth player "just missed statistical significance," said Dr Conidi. "We went back and looked at him with the 2 standard deviation protocol and he actually did meet significance at that point."

Three of these four players had reported sustaining more than 10 concussions. Two players with a positive DTI scan experienced more than 10 headaches a month.

"Traumatic brain injury as measured by DTI MRI appears to be related to increased incidence of concussion and an increase in headache frequency compared to males in the general population," said Dr Conidi.

While these retired football players had no health coverage, "luckily" there is now the settlement of the NFL concussion lawsuit, he said.

The NFL settlement includes a baseline assessment program (BAP) that involves neurologic and neuropsychological testing, said Dr Conidi. "So hopefully at least these athletes will have some access to neurological care."

He hopes to establish a task force to work with the NFL, related organizations and the judge in the case (Judge Brody) to ensure access to care. "We want to set up local areas where the players can go because now, many have to drive or fly 5, 6, or 7 hours" to get assessed, he said.

The BAP will allow researchers to follow these players longitudinally, added Dr Conidi.

In addition to the baseline medical examinations, the settlement is also reported to provide for diagnoses of ALS, Alzheimer's disease, Parkinson's disease, dementia and certain cases of chronic traumatic encephalopathy diagnosed after death, and for education programs and initiatives related to football safety.

The study was limited by its small sample size and by the lack of objective measures of concussions. "Concussion was self-reported and athletes tend to under-report their symptoms," said Dr Conidi.

There was also no objective measure for headache frequency, although researchers have now started to use computerized headache diaries, he said.

White Matter Damage

Following the presentation, Kyle Womack, MD, University of Texas Southwestern, Dallas, commented that "white matter damage is a major risk factor for depression," according to research at his center, which has been "echoed in the large psychiatric literature."

He wondered how Dr Conidi would "untangle" the relationship between depression and white matter damage, given that so many study participants with headache had significant depression.

In an interview with Medscape Medical News, Dr Conidi said he doesn't think that white matter changes are a result of depression in players in his study. "If that were true, one would expect almost all of them to have positive DTI findings," he said. "Our players also had conventional MRI findings which were consistent with diffuse axonal injury, for example, TBI."

However, since white matter changes "could possibly place the retired players at risk for depression," Dr Conidi said he will "certainly include this possibility in future presentations and any publications."

He pointed out, though, that other variables could result in depression in retired football players, including experiencing chronic headaches, realizing that one's memory is failing, and social factors, such as a change in lifestyle.

He also noted that the testing used in the study, for example, the MMPI and MMSE, are "not the most detailed" and are "really just a screen," he said.

The study received no outside funding. Dr. Condi reports being a consultant for the NFL, National Hockey League, Major League Baseball, United States Tennis Association, Professional Golf Association, and National Collegiate Athletic Association and receives research support for "The Seeing Stars" Foundation. He was also contacted about possibly being an expert witness for opted-out players in the NFL Concussion Lawsuit, although he said he is undecided about this because it means not being able to participate in the BAP. He provided unpaid consultation to plaintiff attorney groups involved in the suit but was not an expert witness. He also wrote a letter to Judge Brody about issues with the BAP but is unsure whether the points he made were implemented because he hasn't seen the final BAP agreement.

American Academy of Neurology (AAN) 67th Annual Meeting. Abstract S27.004. Presented April 22, 2015.

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