Women & Concussion: An Under-Recognized Danger

Taken from the November/December 2014 issue of the Women's Health Activist Newsletter.

Since then, happily, there has been a sea change in awareness and understanding of TBI and other head injuries that disrupt normal brain functioning. Still, old beliefs persist that most head injuries are harmless “dings” and primarily a problem faced by male athletes and soldiers.

The reality is that TBI is an equal-opportunity injury; its damages and side effects tilt heavily towards women, due to factors that include inadequate vehicle design, poor symptom recognition, and a lack of research on drugs used to treat female head injuries. Women should be aware of their risks and symptoms, so they can protect themselves and get appropriate treatment.

Inadequate Vehicle Design a Danger to Women

Car crashes are the third leading cause of TBI and the second leading cause of TBI-related deaths in the U.S.1 This is a problem for women because cars are designed for the average male Army recruit; it wasn’t until 2011 that automakers were required to use female crash-test dummies in their safety testing processes.2

As a result, a man and woman sitting in the same car crash are likely to suffer very different injuries. The illustration — in which both drivers are about to be rear-ended — shows why this is so. On impact, the woman, who is sitting forward in the seat, will be clubbed in the back of the head by the headrest. She also sits closer to the steering wheel; an airbag exploding from such a short distance can cause severe injury. The seatbelt (typically placed too high for women) will cut into her neck. The taller male is likely to avoid these injuries.

Both individuals’ necks may hyperflex (“over-bend”) into the space below the headrest, but the man’s stronger muscles and heavier bones may protect him from whiplash. In car crashes, women suffer neck injuries at rates nearly three times those of men.3

Lack of Symptom Recognition for Women’s Head Injuries

TBI can cause a wide range of problems in thinking, sensation, language, and/or emotion.3 Poor recognition of TBI is a problem for all, but symptoms that trigger alarms when men experience them are often ignored in women. Many soldiers have returned from Iraq/Afghanistan with chronic migraine, subnormal body temperature, extreme fatigue, weight gain, depression, and loss of sexual function. In concussed male veterans, they are increasingly being recognized as symptoms of TBI and endocrine disruption — and are being treated. The same symptoms in con­cussed women may, however, be dismissed as “malingering” or “psychosomatic” or simply ignored as a “girl thing.”

Concussion patients are usually warned that they may feel headachy and emotional for a few days. In reality, even “mild” concussion can produce a wide range of symptoms that include memory loss; slowed thoughts and reflexes; light and sound sensitivity; fatigue and poor sleep; problems with vision, hearing, the GI tract, and infertility; Attention Deficit Disorder (ADD) and impulsivity; confusion, and impaired judgment.4

Familiar tasks may become impossible. Imagine the terror of suddenly being unable to make sense of spreadsheets, to manage money, to make a shopping list or cook, or to protect one’s children. After a car crash, a young mother had severe memory lapses. “It is too bad,” she said, “that my children are growing up brain-injured. My memory is so poor [since the accident] that I forgot they were on the changing table, and they fell off. Once I put my infant daughter in the car seat but forgot to buckle the straps; when I had to brake hard, she flew into the front seat and hit the dashboard.”

Symptoms can persist for months or years, long after we think the injured person should be “fine.” Behavior may be so out of character that a spouse or employer may be convinced that these bizarre actions are done on purpose, to be annoying. Failure to recognize the real problem can lead to abuse or divorce, and to a downward spiral of stress and dysfunction that damages individuals, families, and the fabric of society.

Drug Side Effects

Once symptoms are recognized as TBI, the next hurdle is safe treatment. Drugs can be lifesaving, but can also have serious side-effects. Men and women metabolize many drugs differently. One familiar example is alcohol. The impact of many others is unknown because they haven’t been clinically tested on women, only men.5  Until the 1990s, women were left out of many drug trials due to their confounding female physiologies. The menstrual cycle can affect pain response, drug addiction, withdrawal, and even brain injury; the point in a woman’s cycle when her injury occurs impacts both severity and rate of healing.6(Ironically, progesterone, which fluctuates during the menstrual cycle is one of the most promising medications being tested to heal TBI.7

Currently, there are no drugs to treat the cognitive problems caused by TBI. Physicians can only medicate the individual TBI symptoms. Many drugs (for depression, anxiety, and insomnia) can be hazardous to women at standard (male) dosages. For example, women metabolize Ambien / Zolpidem (and related generic sleep aids) so slowly that effects may linger into the next day. Ambien was so strongly linked to traffic accidents that in 2013, the Food and Drug Administration (making its first gender-specific dose recommendation) cut the recommended dosage for women in half.

Prevention, Safety, and Healing TBI Symptoms Without Drugs

Our best approach is to prevent injury in the first place. We can work for better vehicle safety (see www.safercar.gov) and for improved drug testing and awareness of side-effects and interactions (www.drugs.com). We can also help injured brains to heal themselves.

One important approach is known to good moms everywhere: good food, good schedules, good rest. When more help is needed, a relatively new and hopeful option is neurofeedback (a form of biofeedback).

The manuscript on concussion mentioned above (published as Conquering Concussion, see www.round-earth.com) began as case reports on men, women, and children with migraines, memory problems, severe ADD,8 Post-Traumatic Stress Disorder, and other post-concussion symptoms. After neurofeedback treatment, patients experienced positive responses that enabled their physicians to reduce medications, and most subjects were able to return to their jobs, their families, and their lives.9 Overall, take risks and symptoms seriously.

C. M. Shifflett, is a science and technology writer, co-author of Conquering Concussion, and author ofMigraine Brains and Bodies.

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1. Centers for Disease Control and Prevention (CDC), Traumatic Brain Injury in the United States: Fact Sheet, Atlanta: CDC, 2014. Available online at:http://www.cdc.gov/traumaticbraininjury/get_the_facts.html

2. Newcomb D, “Why It Took Decades For a Female Crash Test Dummy to Debut: Automakers for years fought to use only crash dummies modeled after the average American male,” Exhaust Notes, 2012; Aug 30, editorial. See also ABC News report: http://abcnews.go.com/Business/female-crash-dummies-injured/story?id=160... and http://safercar.gov.

3. Grimm RJ, Hemenway WG, Lebray PR, et. al., “The Perilymph Fistula Syndrome Defined in Mild Head Trauma,” Acta Otolaryngologica, 1989;464:1-40. PMID: 2801093.

4. Esty ML and Shifflett CM, Conquering Concussion: Healing TBI Symptoms With Neurofeedback and Without Drugs, Sewickley PA: Round Earth Publishing, 2014; 38-76. See also Colantonio A, Mar W, Escobar M, et al., “Women's health outcomes after traumatic brain injury,” J Women’s Health (Larchmt) 2010; 19(6):1109-16. doi: 10.1089/jwh.2009.1740; Sinopoli KJ, Schachar R, Dennis M, “Traumatic brain injury and secondary attention-deficit/hyperactivity disorder in children and adolescents: the effect of reward on inhibitory control,” J Clin Exp Neuropsychol. 2011; 33(7):805-19. doi: 10.1080/13803395.2011.562864. Epub 2011 May 23.

5. Jackson R, “Gendered Medicine: Psychotropic Drugs Affect Men and Women Differently, in Mostly Unknown Ways,” Scientific American Mind, 2014; 25:15.

6. Wunderle K, Hoeger KM, Wasserman E et al., “Menstrual Phase as Predictor of Outcome After Mild Traumatic Brain Injury in Women,” J of Head Trauma Rehabilitation, 2013; Nov 20. PMID: 24220566.

7. Wright DW, Kellerman AL, Hertzberg VS, ProTECT: a Randomized Clinical Trial of Progesterone for Acute Traumatic Brain Injury,” Annals of Emer­gency Medicine, 2007; 49:4, 391-402. PMID: 17011666.

8. American Academy of Pediatrics, Evidence-Based Child and Adolescent Psychosocial Interventions, 2010; 125, S128, Appendix S2. See also www.braintrainuk.com/wp-content/uploads/2013/07/How-AAP-reached-conclusi...

9. Esty ML and Shifflett CM, Conquering Concussion: Healing TBI Symptoms With Neurofeedback and Without Drugs, Sewickley PA: Round Earth Publishing, 2014; 169.