Football players are at increased risk for a multitude of neurologic conditions, including chronic and episodic migraine, depression, and essential tremor, new research suggests.
A retrospective pilot study of 50 retired National Football League (NFL) players showed a 92% 1-year migraine prevalence rate, with 36% of these participants meeting the criteria for chronic migraine. In comparison, the general US population has rates of 0.5% and 6% for chronic and episodic migraine, respectively.
Among ex-players, chronic nonheadache pain was reported by 88%, while 86% reported anxiety, 78% depression, 78% nocturnal enuresis/bedwetting, and 22% chronic opioid “overuse.”
“Although this all was hypothesis generating, I think it’s worthy of further study,” study investigator Randolph W. Evans, MD, a neurologist in Houston, Texas, with a subspecialty in headache medicine, told Medscape Medical News.
In addition, essential tremor was found in 22% of the participants vs 5% of the general population, with Parkinson’s disease (PD) in 4% and 1%, respectively.
Dr Evans noted that he wasn’t aware of previous reports showing increased prevalence of essential tremor in this patient population.
Although he notes that the cause of this couldn’t be determined even if this finding were confirmed in a randomized study, “damage to the prefrontal cortex is a consideration.”
The results were published in the November/December issue of Practical Neurology.
“Interesting Population”
Because “little is known” about migraine rates in retired NFL players, Dr Evans conducted a pilot study with a sample of 50 consecutive players (mean age, 45.5 years) that he had examined in his own practice.
All of the men were applying for compensation through a settlement the NFL had reached with former players. To qualify for monetary awards, they had to be examined by a board-certified neurologist, neurosurgeon, or neurospecialist “authorized to make a qualifying diagnosis” of cognitive impairment or presence of PD or amyotrophic lateral sclerosis.
“This is an interesting population,” said Dr Evans. “In practice, we often see people who have a single concussion. But how often do we see people with multiple concussions? This doesn’t happen very often, except in professional athletes” — and in Army soldiers with blast trauma, he added.
Among the current study participants, the average age for the start of tackle football was 12.1 years and the average time spent in the NFL was 8.3 years.
In addition, receiving at least one concussion while in the NFL or in college were reported by 92% and 60% of the men, respectively; 44% received concussions in high school. The mean number of concussions reported were 13, 3.2, and 2.3 during NFL, college, and high school play, respectively.
According to the International Classification of Headache Disorders, third edition, 92% of these ex-players met the diagnostic criteria for migraine — with 56% having episodic and 36% having chronic forms of the disorder.
“These data suggest a far greater prevalence of both types of migraine in retired NFL players” than in the general population of men, writes Dr Evans.
“Poorly Understood” Causes
The mean age at migraine onset was 33 years, with 48% having onset while playing in the NFL and 48% during retirement. Only 4% reported migraine onset before their NFL careers.
Although the mean score on the Headache Impact Test-6 was a “substantial to severe” 58.9, only 35% of the migraineurs reported seeking clinical treatment.
“The causes of post-traumatic migraine remain poorly understood. Possible mechanisms include diffuse axonal injury, release of excitatory neurotransmitters, impairment in cerebral vascular autoregulation, and neuroinflammation,” Dr Evans writes.
“Chronic traumatic encephalopathy…may also be associated with headaches,” he adds.
The former football players also had very high 1-year prevalence rates for other neurologic conditions.
Table. Group Comparisons in Neurologic Outcomes
| Outcome | Ex-NFL Players (%) | General Population (%) | ||
|---|---|---|---|---|
| Anxiety | 86 | 7.5 | ||
| Depression | 78 | 6 | ||
| Bedwetting | 78 | 7a | ||
| Essential tremor | 22 | 5 | ||
| PD | 4 | 1b | ||
| aIn general population of male adults only.
bIn general population older than 50 years. |
||||
Chronic pain in the neck, back, joints, hands, and/or feet was reported by 88% of the participants, with all but one noting that onset occurred during their NFL years.
“Studies have shown that non-headache pain…increases the risk of chronic migraine,” notes Dr Evans.
Finally, 11 participants with chronic pain reported using prescription opioids at least 8 days per month, which was classified as “opioid overuse.”
Dangerous Occupations
“Findings suggest that retired NFL players may be at increased risk for” multiple disorders, Dr Evans writes. “Confirmation…in a population-based sample of the approximately 22,000 retired NFL players would be of interest.”
He adds that future studies should also assess cognitive impairment, other potential risk factors for chronic migraine (such as sleep-disordered breathing and obesity), and diffusion-tensor MRI of the brain.
“In addition to the relatively small population of 22,000 former players, you have a large number of high school and college players. And you have about 300,000 soldiers who were exposed to blast trauma in Iraq or Afghanistan,” Dr Evans told Medscape Medical News.
“The question is: Do these findings apply to other populations? And they may. Pilot studies can ask some interesting questions, but bigger studies are needed to see if the findings hold up.”
When asked what his opinion is now on the football culture in United States, Dr Evans said, “Football for many of us is still enjoyable to watch. But after seeing so many retired players, it’s hard for me to watch without thinking about what the long-term cost to these players might be.”
He noted that there are other jobs and sports with high risk for injury. “There are soldiers and race-car drivers, bull riders and rodeo clowns. We don’t outlaw people from doing dangerous occupations,” he said.
“The NFL has made positive moves to try and eliminate injuries with concussion protocols, but we don’t know if that’s made a difference or not. There’s no long-term data.”
Dr Evans is on the editorial board for Medscape Neurology. He writes that the study is not endorsed or authorized “by the NFL Concussion Settlement Program, the parties to, or the administrators of that settlement.”
Pract Neurol. 2017;Nov/Dec:21-25. Full text
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