We're more likely than men to get them. We're more likely to suffer long-lasting effects. And the scary part is, experts don't fully know why. But there are critical steps you can take to better protect your brain so that a ski spill or bike tumble doesn't turn into a serious health crisis.
© Jonathan Knowles 2015
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Six years ago, Erin Lopez bent over to pick up a toy her then 3-year-old son, Tyler, had dropped underneath her kitchen table and, standing up, she slammed her head. “I always thought the expression ‘seeing stars’ was an exaggeration, but I literally saw spots dancing everywhere,” says the 39-year-old stay-at-home mom, who lives in Fairfield, Conn. The pain subsided after a few minutes, and she soon forgot about it. But later that night, she was hit with intense nausea that lasted for hours. “I didn’t even make the connection. I wondered, ‘What did I eat that’s making me sick?’”

A few days later, Lopez developed a severe headache—pounding pain that waxed and waned throughout the day but was always present. “I was taking Advil like crazy, and it still wouldn’t go away,” she says. When the pain didn’t abate after a week, her husband insisted she see her doctor. “I was talking to the nurse practitioner, describing my symptoms, and I mentioned, almost as an afterthought, that I’d banged my head on the table about 10 days earlier,” she says. “The nurse said immediately, ‘You must have had a concussion.’ I was floored. I’d always assumed you got a concussion playing sports or by being in a car accident; I never thought it could happen while I was giving my toddler lunch.”

When you think of women and concussions, you might think of Lindsey Vonn taking a tumble on the slopes or Dutch cyclist Annemiek van Vleuten flipping over her handlebars and landing on her head during the Rio Olympics. Yet a concussion—a type of brain injury resulting from a bump, blow, or jolt to the head—can happen to any of us, not just über-athletes. In fact, rates of emergency room visits related to traumatic brain injury (including concussions) among women almost doubled from 2001 to 2010, according to the Centers for Disease Control and Prevention (CDC). These injuries can be caused by not only sports but also falls, car crashes, blunt trauma (getting hit on the head by an object), and assaults. An alarming report published this year in Family & Community Health found that at least 60 percent of abused women have had a traumatic brain injury due to domestic violence.

Studies have shown that women are more prone to concussions than men. “When we compare men and women playing the same sport, we find that female rates of concussion are significantly higher than those for males,” says Jeffrey Bazarian, MD, a concussion specialist and professor of emergency medicine and physical medicine and rehabilitation at the University of Rochester in New York. Women also tend to have longer-lasting symptoms and take longer to recover overall, research shows.

These risks matter because the potential long-term health consequences of concussions are serious. People who have had multiple concussions are at higher risk of developing a condition called chronic traumatic encephalopathy (CTE), a progressive degenerative disease found in the brains of former athletes and others who have experienced repetitive brain trauma like concussion. (Last spring, U.S. soccer icon Brandi Chastain pledged to donate her brain to CTE research after she dies.) This is what scientists know now that may just help you avoid a worst-case scenario.

Why women fare worse

When you bang your head, the hard shell of your skull helps protect your brain’s soft tissue from direct impact, while fluid around the brain acts as a shock absorber. But a violent-enough jolt can fling your brain against the inside of your skull, triggering bruising as well as blood vessel and nerve damage. Concussions can’t be spotted from the outside, nor can they be seen with imaging tools like MRIs or CT scans, which is why doctors rely on symptoms (such as nausea, headache, confusion, dizziness, memory problems, and loss of consciousness), as well as neurological exams, cognitive testing and other forms of assessment, to make the diagnosis. (Researchers are currently working to develop a
blood test to help identify brain injuries.)

Compared with men, women have about 1.5 times greater risk of concussion in soccer and 1.4 times greater risk in basketball, and women playing softball have nearly twice the risk of men playing baseball, per the National Collegiate Athletic Association Injury Surveillance Program. “For a long time, we assumed that women were simply more likely to report concussion symptoms than men, but research now shows that’s not the case,” says James Borchers, MD, a sports medicine specialist at The Ohio State University.

We may even sustain more severe concussions than men: In a recent study of 207 male and female athletes at a concussion specialty clinic in Ontario, the clinic’s medical director, Shannon Bauman, MD, found that women didn’t just report more symptoms of concussion post-injury but also had more objective signs (according to a physical exam and their medical histories), such as migraine and trouble maintaining balance.

Not so clear, however, is why. One theory is that women, even athletes, tend to have less neck strength than men. The weaker your neck, the more vulnerable you are to a concussion, a 2014 study suggested. “Very few women work on neck strengthening, either because it doesn’t occur to them or because they worry about developing a more muscular neck,” says study author Robert C. Cantu, MD, medical director and director of clinical research for the Dr. Robert C. Cantu Concussion Center at Emerson Hospital in Concord, Mass. “But the weaker your neck, the more likely it is that your head will get whiplashed, which increases the rate at which your brain moves around in your skull.” As a result, you can suffer a more serious concussion.

Research also suggests that women are more apt to get post-concussion syndrome, in which symptoms like headaches and dizziness last for weeks, even months, after injury. In Dr. Bauman’s study, only 12 percent of women had recovered completely after two months, compared with about a third of the men, and 35 percent of women still had symptoms six months later.

This slower healing may be related in part to hormones. Women injured during the two weeks before their period had a slower recovery and poorer health one month after injury than those who either got hurt in the two weeks post-period or were taking birth control pills (which smooth out monthly hormonal ups and downs), according to a 2013 study authored by Dr. Bazarian. “When a woman gets a concussion, her pituitary gland—a pea-size gland attached to the base of the brain—may get shaken up a bit and stop making the hormone that stimulates estrogen and progesterone,” explains Dr. Bazarian. “We think that if a woman gets hit at a point in her cycle when progesterone is high, usually the two weeks before her period, the pituitary shuts down, and progesterone—which promotes brain cell growth and has a calming effect on the brain—drops very quickly, causing a sort of withdrawal effect that worsens post-concussion symptoms.” More evidence that hormones are at play: Girls who haven’t started menstruating yet and postmenopausal women have outcomes similar to men’s, adds Dr. Bazarian.

Avoiding long-term dangers

The good news is that if you had a couple of concussions playing sports in high school or college, or suffered one as an adult, the risk of severe lingering or permanent damage is low, says Christopher Giza, MD, director of the UCLA Steve Tisch BrainSPORT Program. The key is to make sure you don’t get a second concussion while still recovering from the first. “We know from animal data that if concussions happen close together, it can cause longer-lasting impairments, but if you spread out the concussions far enough so that animals seem to recover completely, you don’t have these effects,” says Dr. Giza.

Unfortunately, some women (as well as men) seem to suffer concussions one after the other, a phenomenon that concerns and mystifies researchers. Katherine Price Snedaker, executive director of the nonprofit Pink Concussions, has suffered more than 20 of these head injuries over the last 35 years. “I got my first one playing field hockey at age 16 and started getting one every couple of years after that,” she says. “One time it was a car accident; another time I fainted and banged my head against the wall; another time I hit my head on my car door.”

Getting multiple concussions is probably due to more than just terrible coincidence: One JAMA study found that having three or more concussions triples a person’s risk of future ones. “It could be due to genetic factors, or simply to the fact that these people tend to be more active or have more risk-taking behaviors, like acting aggressively during competitive sports,” theorizes Dr. Giza.

But while the cause is unknown, the phenomenon is particularly worrisome because women who suffer repeat concussions may also be susceptible to CTE—the same disease that’s grabbed so many headlines lately in relation to professional football players. “CTE makes the brain tissue progressively degenerate and also leads to the buildup of abnormal proteins called tau, which can result in memory loss, confusion and, long-term, conditions such as depression and dementia,” explains Dr. Giza. The disease was originally identified in male boxers (it used to be known as dementia pugilistica); in the early 2000s, postmortem examinations of pro football players revealed CTE in their brains, too. Now experts realize it can happen to anyone who has had repeated brain trauma.

How to protect yourself

Though you can’t bubble-wrap your entire world, there are some effective ways to shield yourself from concussions and their aftereffects.

Improve your balance. “Women in their 30s and 40s should be regularly doing exercises that improve balance, like walking heel-to-toe or standing on one leg, or even tai chi, to reduce the risk of having a fall later in life that could result in a concussion,” says Dr. Giza.

Strengthen your neck. You can do simple exercises at home to boost neck strength, which may make you less vulnerable to concussions. “Your neck moves in three planes: It flexes and extends, rotates left and right and tilts left and right,” explains Dr. Cantu. “You can do those three motions using your hand against your head as resistance.” Start with 12 to 15 reps of each; increase the resistance once you can easily do three sets of 15 reps. Ideally, you should do these exercises every other day, says Dr. Cantu. (And, no, you won’t get a muscled-up neck, he adds.)

Know your risk. Women are most likely to get a concussion playing team contact sports, such as soccer, basketball, and softball, found a 2013 study published by Dr. Giza in the journal Neurology. According to the University of Pittsburgh’s Brain Trauma Research Center, the likelihood of suffering a concussion while playing a contact sport is estimated to be as high as 19 percent per year of play.

Wear a helmet when needed. For certain activities (bicycling, skiing, in-line skating, rock climbing, and horseback riding, to name a few), a helmet is a must. Helmets can’t prevent a concussion, but “since a helmet is designed to absorb some of the energy of an impact, they do slow the rate at which your head decelerates, which can potentially lessen the effects of a concussion,” explains Dr. Giza. Wear a helmet that meets the specific safety standards for your sport or activity (check the label); don’t wear a bike helmet to go skiing, for example, or vice versa.

Suspect a concussion? Get examined. Anytime you hit your head, be on high alert for signs of a concussion. These include headache, dizziness, nausea or vomiting, difficulty thinking clearly, fuzzy or blurry vision, mood changes (like feeling sad or irritable), trouble remembering new information, sudden and unexplained fatigue, sleeping more or less than usual, or feeling slowed down. If you or those around you notice any of these symptoms, call your primary care physician, who can help make the decision whether you can safely monitor your symptoms at home or need to come in immediately (or go to the ER). While a concussion itself isn’t life-threatening, it’s important to get properly diagnosed.

Make sure you fully heal. “The worst thing you can do is ignore a concussion and push through symptoms,” says Dr. Borchers. “You’ll just worsen the damage, and it will take longer to recover.” There is no one-size-fits-all treatment plan, but in general, as long as you’ve got symptoms, avoid physical activity and limit using computers, texting, reading and doing anything that requires concentration. You don’t, however, need to lie in a quiet, dark room for days. “There’s actually evidence now that it creates more mental distress, anxiety and a longer recovery period,” says Dr. Giza. Once symptoms start improving, you can begin resuming regular activities—but, again, don’t overdo it. Plan on working a reduced schedule, if you can, and performing light exercise, like walking, before jumping back into your old workout routine. If your symptoms return, that’s a sign you need to scale back again and give yourself more time to heal.

Fortunately, most people recover with minimal aftereffects. What’s crucial: doing everything in your power to avoid getting injured again, especially soon afterward, something Snedaker learned the hard way. After years of having her repeat concussions downplayed by doctors, she’s now on ADHD medication to help manage the cumulative effects, including short-term memory loss and distractibility. “It’s like everything is in the filing cabinet, but it’s not filed correctly,” she says.

As more doctors become aware of the role gender plays in concussion, and as more research is done, stories like Snedaker’s will hopefully become rarer. But while it’s reassuring to know that scientists are studying the issue, you still need to be proactive about your own health. “Treatment starts with education, which means not ignoring symptoms,” stresses Dr. Giza. “Our brains do a great job of healing themselves, as long as we let them.”

When to go to the ER

If someone develops any of the signs below after a head injury, call 911 or get her to the emergency room. Per the CDC, these symptoms could indicate a blood clot or other serious problem. (Not sure whether you should get checked out? Call your doc or go to the ER to be safe.)

  • Loss of consciousness
  • A headache that worsens and doesn’t go away
  • Weakness, numbness, or problems with coordination
  • Repeated vomiting or nausea
  • Slurred speech
  • Extreme drowsiness
  • One pupil larger than the other
  • Convulsions or seizures
  • Inability to recognize people or places
  • Confusion, restlessness, or agitation