Pediatric Sports Neurology Perspective on Headaches and Migraines

Pediatric Sports Neurology Perspective on Headaches and Migraines

by | Apr 28, 2022 | Sports Medicine

Mathew Stokes, M.D., is a pediatric sports neurologist and headache specialist at UT Southwestern Medical Center and also sees patients at Scottish Rite for Children in Frisco. These resources are designed to help medical professionals recognize and manage sport-related concussions and headaches in children and adolescents.

Sports Neurology: Concussion and Headache in Young Athletes

Mathew Stokes, M.D.

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Stokes presented this lecture as part of a monthly education series for medical professionals. He described common symptoms including physical, emotional and cognitive changes associated with sport-related concussion. He presented risk factors associated with delayed recovery from concussion. Finally, he provided criteria for diagnosis, management and prevention of common headache types in athletes including migraines.

Non-Pharmacological Management of Migraines

Victor Kaytser, M.D., and Mathew Stokes, M.D.

Stokes, M.D., co-authored this article with UT Southwestern Medical Center neurology fellow, Victor Kaytser, M.D. The article was originally published in a recent newsletter of the Pediatric Society of Greater Dallas.

Download the PDF of this article.

What Is a Migraine and How Are They Treated?

Migraines are a common neurological disorder affecting one in 10 children, with a higher incidence in teenage girls. (Symptoms of migraine or what is not considered a migraine?)

As we learn more about migraines, we are finding new and innovative ways to treat them. This is especially important for patients who cannot take or do not respond well to the traditionally prescribed pain-relieving and preventive medications. In addition, parents may feel hesitant to medicate their children and will seek non-pharmacological remedies first. Therefore, we will discuss some non-pharmacological options for the treatment of migraines including lifestyle modifications, supplements and devices.

Lifestyle Modifications

Lifestyle modifications are recommended regardless of what other treatments may already be in place and can be remembered using the mnemonic SEEDS: Sleep, Exercise, Eat, Diary, Stress.

Sleep
Migraines can be caused by too much or not enough sleep, and disruptions in the normal 24-hour sleep cycle, or circadian rhythm. Poor sleep habits can trigger migraines, and migraines, in turn, make it difficult to sleep, further exacerbating the pain cycle. A few sleep hygiene tips are as follows:

  • Schedule a consistent sleep time and wake time, including weekends.
  • Do not use the bed/bedroom for other activities, such as studying, watching TV, etc.
  • Avoid staying in bed if wide awake; rise and do something else for a few minutes before trying to fall asleep again.
  • Take time outside to help set a natural circadian rhythm.
  • Do not exercise before sleep.
  • Avoid stimulants, such as caffeine or nicotine.

Exercise
At least 30 minutes of moderate-intensity exercise, three times per week can help reduce migraine frequency and severity. Patients should note that overexertion can worsen headaches. Those involved in contact sports need to be mindful that injuries and head trauma can also worsen headaches.

Eat
Both high and low blood sugar levels can affect migraines. Therefore, eating smaller meals, increasing protein, fiber and healthy fat intake while also reducing processed foods can help maintain healthy glucose levels and reduce migraine frequency.

Maintaining a caffeine-free diet is ideal; however, if patients currently consume caffeine, stopping the consumption suddenly can lead to caffeine-withdrawal headaches. Therefore, a slow weaning of caffeine products is recommended. Other foods that are commonly migraine triggers include aged cheese, chocolate and MSG.

Water intake is also important. The daily goal is one ounce per kilogram of body weight. (1 KG = 2.2 pounds)

Diary
A headache diary can help to identify migraine triggers. Triggers can vary from environmental (e.g., bright lights, weather changes) to nutrition, sleep changes or stressors. Identifying migraine triggers can help patients focus their lifestyle change efforts. Options include Migraine Buddy and iHeadache mobile apps.

Stress
To effectively manage stress, many turn to cognitive behavioral therapy, meditation, mindfulness, massages and yoga. There are free websites, like www.dawnbuse.com, that provide various relaxation audio files, articles and podcasts.

Supplements

Nutraceuticals
Riboflavin (vitamin B2), CoQ10, magnesium, curcumin and feverfew (Tanacetum parthenium) are the most commonly used for migraines. These nutraceuticals have positive effects on mitochondrial metabolism, antioxidant properties and are vasoconstrictors, helping to prevent or relieve pain in migraine sufferers. Several proprietary products, like Migrelief and Dolovent, combine these supplements in a single formula.

Magnesium acts as a calcium channel antagonist and has the most robust body of literature supporting its effects on migraine with a relatively low side effect profile (abdominal discomfort and diarrhea).

Therapies

Essential oils
Peppermint oil contains menthol, which can help ease pain by relaxing the muscles around the head. Rosemary oil has anti-inflammatory and pain-easing characteristics. Lavender and chamomile oil is used to help relax and reduce stress. Eucalyptus oil helps to open and clear the sinuses, which, if congested from allergies, may provoke headaches.

Heating and cooling pads
Placing a hot compress on the neck can help relax tense muscles and relieve pain. A cold compress or ice pack can provide relief through its numbing effect, temporarily dulling the sensation of pain when placed on the neck and/or forehead.

Acupuncture
Used for centuries to treat pain and manage stress, acupuncture has been shown to be at least as effective as some standard drugs like beta blockers and topiramate, and it is safer and more cost effective.

Devices

Medical devices like gammaCore, an external vagus nerve stimulator, can also help. The device is held against the skin of the neck and transmits small electrical currents to stimulate the vagus nerve and block pain signals. The device works in as little as 30 minutes, and 30% of patients were pain-free at two hours. About one-third of patients achieved a 50% reduction in headache frequency.

Nerivio is a neuromodulation device for patients 12 and older, worn on the upper arm to stimulate small nerves that send pain signals to the brain. A third of patients were completely pain-free at two hours.

Cefaly is an external trigeminal nerve stimulation device for patients 18 and older and does not need a prescription. The device is magnetically connected to a reusable self-adhesive electrode that is placed on the center of the forehead and sends micro-impulses to the trigeminal nerve. Studies reported that 32% of patients were pain-free at one hour, and 38% saw at least 50% reduction in migraines per month.

Allay Lamp emits a precise narrow band of green light that helps reduce the light sensitivity associated with migraine, which can also help reduce stress, anxiety and improve sleep.

Conclusion

Helping patients identify migraine triggers and follow daily headache hygiene tips can go a long way in composing an effective treatment plan. In some cases, lifestyle changes may be enough to reduce migraine frequency considerably and avoid the need for devices or medications all together. For others, a combination of lifestyle changes with a device, supplement or medication may be the most effective. For the latest migraine management tips, the American Migraine Foundation website routinely publishes new articles to better manage migraines.

Muscle Strain Q&A

Muscle Strain Q&A

by | Apr 22, 2022 | Sports Medicine

Our world-renowned sports medicine experts are ready to help your injured athlete get back in the game. We have unparalleled experience providing nonoperative and arthroscopic care to treat common sport-related injuries including concussions, ligament injuries and cartilage conditions in the knee, ankle, shoulder, elbow and hip in young and growing athletes.

Sports Medicine expert Jacob C. Jones, M.D., RMSK, shares information about muscle strains and how to handle these types of injuries in young athletes.

What is a muscle strain?
A muscle strain is a disruption of the muscle fibers in a certain muscle group. Muscle strains can be mild or they can be severe, causing muscle tearing.

What causes a muscle strain?
Muscles are constantly being pushed and pulled, but when a muscle contracts at the same time that it is being pulled, a strain can occur. This type of muscle movement is called an eccentric contraction. 

What are the symptoms of a muscle strain?
In mild strains or low-grade muscle disruptions, the most common symptom will be pain in the area. Severe disruptions or tears can also cause swelling, more noticeable weakness, and even bruising.

Should you seek medical treatment for a muscle strain?
It is definitely wise to seek medical treatment for muscle strains. In mild cases, a young athlete may want to consult with their athletic trainer for advice and recommendations on reducing the pain. Athletic trainers can also help determine whether the athlete needs to see a physician for the injury.

Relative rest, in combination with muscle rehab, is the best treatments for a strain. It is important to allow the muscle to heal while also building strength and flexibility to avoid further injury. Even in high grade muscle tears, surgery may not be commonly recommended. 

Are certain muscles more at risk for strains?
Yes, muscle groups that are at the highest risk for strains are those that cross multiple joints. For example, some hamstring and quadricep muscles cross both the hip and knee joints and calf muscles cross the ankle and knee joints. Any muscle can be strained, but those groups are more likely to be injured.

How can you avoid muscle strains?
Muscles are less likely to have a strain if they are flexible and strong. Stretching daily can help provide your muscles with more flexibility and strength. Additionally, it is important to also warm up your muscles before working out or playing a sport. Muscles are less likely to strain or tear when they are warm, so it is important to not skip warm-ups before practice.

What does recovery from a muscle strain look like?
Once pain allows, it is important to do some rehabilitation to the muscle before returning to regular activity. In mild strains or low-grade disruptions, recovery time may take weeks. In more severe cases that lead to muscle tears, recovery time may take months. We look for good range of motion, minimal to no pain, and good strength prior to return to sport.

What happens if an athlete returns to sports or activity before the strain is healed?
The biggest risk of returning to athletics or sports too soon is re-aggravating the muscle and extending the recovery time. Additionally, having a strain may cause you to favor one leg or arm and could lead to further injury.

How can ultrasound be used to diagnose and treat muscle strains?
Specially trained experts can use musculoskeletal ultrasound to evaluate injured joints, ligaments, tendons, muscles and bones. Ultrasound can visualize soft tissues like muscle well with a high level of detail. When looking at a muscle using ultrasound, a low-grade strain may show some edema, swelling caused by fluid in tissue, while a more severe strain that has already torn will clearly be visible. Using ultrasound can also allow physicians to determine where additional treatment or care is needed in treating muscle strains. Ultrasound can also be used for treatment of chronic muscle tears not improving with other conservative measures.

Sports medicine is a medical and surgical specialty that considers the comprehensive needs of athletes and provides management for sport-related injuries and conditions. Young and growing athletes are highly competitive and have unique conditions that require care by a pediatric team of experts. Learn more about our Center for Excellence in Sports Medicine and how board-certified pediatricians, pediatric orthopedic surgeons, physical therapists, athletic trainers, psychologists and other sports medicine specialists work side-by-side with each athlete, their parents and coaches to develop the best game plan for treatment, rehabilitation and safe return to sport.

D Magazine: How Collin County’s Healthcare Providers Are Managing Record Population Growth

D Magazine: How Collin County’s Healthcare Providers Are Managing Record Population Growth

by | Apr 13, 2022 | Press Coverage, Sports Medicine

Collin County is the fourth-fastest growing county in the country. Growth can present all sorts of challenges for professionals working in education, healthcare, transportation and every other area of public life.

Philip L. Wilson, M.D., was part of a panel of Collin County leaders, talking about how their organizations met the challenge of keeping people healthy in the midst of a population explosion. 

Read the full article. 

Study Looks at Re-Injury Rate After ACL Reconstruction in Young Athletes

Study Looks at Re-Injury Rate After ACL Reconstruction in Young Athletes

by | Apr 12, 2022 | Dyslexia & Learning Disorders

Wrapping up his third year as a medical student at UT Southwestern Medical School, Craig Kemper, B.B.A., has participated in several projects with the Center for Excellence in Sports Medicine research team. Kemper was the lead author on a project looking at athletes who were back to sport after an anterior cruciate ligament (ACL) tear and reconstruction that was recently presented at the 39 annual meeting of the Mid-America Orthopaedic Association. The organization comprises orthopedic surgeons from 20 states, including Texas.

Know a medical student who may be interested in working with our clinical research team? Connect them with Nancy Kleg to learn more!

After surgery for the “primary” ACL tear, as many as 1 in 4 young athletes re-tear the reconstructed ACL or the ACL in the other knee. The rate for these “secondary” ACL tears in young athletes is a concern for researchers and clinicians in pediatric sports medicine. This review included patients seen over three years at Scottish Rite for Children for an ACL tear and reconstruction to determine whether participation in multiple sports protects against re-injury.

The 145 patients in the study were

  • an average age of 14 years.
  • 50% male, 50% female.
  • > 50% reported playing only one sport (single-sport athletes)
    • Most played soccer.
    • On average, these athletes returned to sports in fewer days than multi-sport athletes.

Kemper says young athletes continue to feel pressured to choose one sport at earlier ages to “not be left behind.” Many recommend multi-sport participation to help an athlete develop varied skills and protect from overuse injuries unique to growing children, including apophysitis and osteochondritis dissecans.

“We give this advice, but we aren’t sure if it applies to this population regarding re-injury after an ACL reconstruction,” says co-author and Medical Director of Clinical Research, Henry B. Ellis, M.D. “The time out of sports is already so long for an ACL tear, we are eager to learn all the variables that contribute to re-injury rates. Other studies have looked at surgical techniques, but this one looks at sport-participation and time to return-to-play.”

Although single-sport athletes were cleared to return to sports in a shorter time than multi-sport athletes, the analysis found no difference in the rate of secondary ACL injuries within two years of follow-up for this group. “Results like this are still helpful and give direction for future projects,” says Ellis. “More importantly, they help me as a pediatric orthopedic surgeon know how to counsel my patients.”

 

SINGLE-SPORT ATHLETES NOT EXPERIENCING INCREASE IN SECONDARY TEAR INCIDENCE DESPITE EARLIER CLEARANCE, Craig Kemper, B.B.A., K. John Wagner, III, B.S., Connor M. Carpenter, B.B.A., David E. Zimmerhanzel, B.S., Philip L. Wilson, M.D., Henry B. Ellis, M.D.

Learn more about ACL injuries on our website.

5 Common Questions About Limb Lengthening

5 Common Questions About Limb Lengthening

by | Apr 6, 2022 | Limb Lengthening

At Scottish Rite for Children, the Center for Excellence in Limb Lengthening and Reconstruction includes a multidisciplinary team of experts who collaborate to determine the best treatment plan for each patient. We know there are a lot of questions if your child begins treatment for their limb length discrepancy. Below are the most commonly asked and the answers from our team. 

Do I Have to Have Surgery?

If the difference between the lengths of your limbs is significant (more than 1 inch), surgery may help to prevent problems in the future. For small limb length differences (1-2 inches), sometimes a small surgery (an epiphysiodesis) that slows down the growth of the long leg and allows the shorter leg to grow and catch up is all that is needed. For bigger limb length differences, lengthening the short leg is needed. There are different techniques for lengthening a leg, including lengthening rods that are placed inside the bone or an external fixator, an advanced device developed at Scottish Rite for Children that is around your leg and attached to your bone. The type of device used is frequently determined by the cause of your leg length difference. The Limb Lengthening and Reconstruction team will explain the best technique for you. Both techniques lengthen the bone very slowly over several weeks. 

How Does the Limb-Lengthening Device Work?

When using the lengthening rod, the doctors separate the bone in your shorter limb and insert the rod inside the bone. The rod will be secured to the bone at each end of the rod. After surgery, you will use a device that rests on your leg to activate the rod to slowly lengthen and separate the bone a little bit each day.  

The external fixator, the TL Hex External Fixator System, has rods that are attached to each side of the separated bone. These rods are connected to rings attached to the outside of your limb. Every day, you will turn struts that connect the rings and cause the rings and the bone to slowly separate and lengthen. The frame will support your limb while the rods help the bone to grow. 

Will Limb Lengthening Hurt?

During surgery, you’ll be under anesthesia, so you won’t feel a thing. Whether you use the lengthening rod inside the bone or the external fixator, there is soreness as the bone and muscles lengthen. Your doctor will be able to give you medication to minimize the pain. In addition, Scottish Rite for Children has pediatric psychologists who will teach you other ways to manage your pain.

How Long Will Lengthening Take?

The amount of time you will need to wear the frame will be determined by how much your limb needs to grow. Regardless of the technique, for most patients, it takes six to nine months from the time of surgery to the time you are back to running and jumping. Most of the bone lengthening actually takes place in the first few months. After that, it takes time for the bone to fully heal and for you to get your full strength back.

When Can I Return To My Normal Activities?

After you spend a little time healing from your surgery, getting back to as normal a routine as possible is really important. Lengthening your leg and doing your daily exercises becomes part of your regular day. You will go back to school and participate in many of your typical activities. If you have a lengthening rod, you will not be able to put all of your weight on the leg being lengthened and will have to use crutches until the bone is almost completely healed. If you have an external fixator, the frame will support your whole body weight and after a few weeks you won’t need crutches. While you are lengthening your leg, you will visit the doctor every week, but once the lengthening is completed, you will only need to visit monthly.