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Traumatic Brain Injury

Gender Differences Complicate Concussion Care

Concussions win the battle of the sexes, but the contrasts are key to prevention

High school girls soccer is a growing concussion concern.

Concussions do not discriminate, and recent studies show distinct gender differences may complicate sports concussion management care. While concussions among male professional and veteran athletes grab the lion’s share of media coverage, studies suggest females have a higher incidence rate of concussions. And, that’s just the beginning of the differences between the genders.

I’ve treated hundreds, if not thousands of concussions, and recognize that everybody, every brain, every mild traumatic brain injury differs. But for parents, coaches, athletic trainers even athletes themselves, acknowledging gender-based differences ultimately leads to greater respect for the injury itself.

I’ve broken down gender-based considerations based on incidence rates, pre-season baseline testing, the concussion injury itself, and differences related to recovery.

1. Incidence Rates Among Women Climbing

In “Epidemiology of Concussions Among US High School Athletes in 20 Sports,” a study published in 2012, the top four sports reporting concussions were split among men and women:

  • Football (47.1%)
  • Girls’ soccer (8.2%)
  • Boys’ wrestling (5.8%)
  • Girls’ basketball (5.5%)

A growing concern is concussions in high school girls soccer. Studies show girls are reporting nearly twice as many concussions as boys. Not only that, but the number of girls suffering concussions in soccer accounts for the second largest amount of all concussions reported by young athletes, according to the Center for Injury Research and Policy in Columbus, Ohio.

Additionally, between 2004 and 2009, the NCAA’s rate of concussion per 1,000 practices and games for women’s soccer was 2.2 compared with 1.4 for men. In basketball, women had an average 1.2 concussions, while men had 0.6, according to college sports’ governing body. Football players led the survey with 3.1 concussions per 1,000 practices and games.

2. Baseline Differences Provide Insight To Detection

In my own clinical study, performed from 2012-2013 with 1366 high school and collegiate athletes in Maryland, we found female athletes were more likely to endorse (or acknowledge) pre-season concussion-related symptoms within five of seven domains measured.

Using a Sport Concussion Symptom Checklist, provided by XLNTbrain Sport (, participants scored their frequency experiencing concussion-like symptoms at the beginning of the season and within the following domains: Cognitive, vestibular (balance), sleep, migraine, mood, worry and anger. We found female athletes more likely to endorse symptoms in the migraine, vestibular, sleep, worry, and mood domains.

The primary learning is gender differences in baseline testing provide insight to assessing athletes for concussion during the season. Not only are baseline tests critical to providing quality concussion management, but gender differences help the athletic trainer — or the team’s concussion coordinator — discover, monitor and treat the concussion more individually and accurately. Secondly, the greater prominence of pre-season concussion symptoms among women points to the increased risk of exacerbating those issues with a concussion.

Women recover faster, but with harsher symptoms.

3. Women More Vulnerable to Concussion Injury?

Women recover faster, but with harsher symptoms.

3. Women More Vulnerable to Concussion Injury?

Concussion risk has little to do with gender, in my opinion, and more to do with the type of sport, and the individual’s previous history of head trauma, lifestyle habits, and other cognitive, emotional and behavioral issues that effect brain health.

However, some theories suggest women suffer more concussions due to physical differences. Because women have more slender necks and smaller heads, they can experience nearly 50 percent more head acceleration during head trauma. In addition to physical differences, hormonal differences may also lead to more concussion symptoms in women versus men. Research has suggested that female athletes may also suffer more severe concussions, leading to a greater impact on cognitive function (thinking abilities) and longer recovery periods.

However, other studies failed to find significant differences in concussions between the sexes. In a study of 15,802 high school athletes in North Carolina, male soccer players reported more concussions than females, while female basketball players reported more concussion incidents than males.

Another research project reviewed thousands of studies to find a link to concussion risk and gender. The results from these studies suggest that in sports where rules and physicality are more equal between sexes, such as soccer and basketball, women appear to be at greater risk.

Despite being the physically stronger sex, one study suggests the male brain displays more evidence of concussion injury. Using a particular form of MRI, called diffusion tensor imaging (DTI), the study looked specifically at the brain's white matter, where a concussion may cause tears in the connective fibers.

The DTI scans suggested that, compared to women with concussions and participants without brain injury, men with concussions had more abnormalities in one area of the brain's white matter, called uncinate fasciculus, which is a bundle of fibers that connects two major regions of the brain.

Additional research found girls and women are more likely to suffer concussions than boys and men in comparable sports such as soccer, basketball and baseball/softball.

Despite all these studies suggesting one sex is at greater risk than the other, the main factor to determine risk is the health of the brain prior to the concussion. For example, if an individual’s brain shows signs of toxicity from drinking too much alcohol, smoking cigarettes, drug use or exposure to significant duration of dangerous fumes, the individual may be more susceptible to concussion injury. Previous head trauma, whether resulting from sports or not, may also “weaken” the brain’s ability to sustain stress caused by a hit to head. A personal or family history of migraines may predispose an athlete to concussion injury.

4. Post-Concussion Recovery Differences Exist

After sustaining a concussion, men may take longer to recover while women may have more symptoms, greater cognitive decline and poorer reaction time as compared to baseline scores.

In one study, researchers examined brain scans and medical records of 47 men and 22 women with concussions, and a group of 21 men and women without any brain injury, to see whether gender has any role in recovery from mild injuries to the brain. The results showed that it took men with concussions an average of 67 days to recover, compared with an average of 26 days for women.

Women, on the other hand, tend to have worse symptoms than men. Some recent studies have found gender differences in memory and other symptoms after concussions, with women generally doing worse. In one study, concussed female athletes exhibited lower performance on visual memory composite scores and higher scores on total symptoms than male athletes.

Another study suggests women of child-bearing age have higher progesterone levels which may contribute to and worsen post-concussion symptoms.

While gender differences exist, the human brain was not designed to sustain enough force to cause concussion. Understanding the gender differences can help guide detection and treatment protocol, but ultimately concussions win the battle of the sexes.

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Cognitive neurologist Harry Kerasidis, M.D. is the Founder of Chesapeake Neurology Associates in Maryland and XLNTbrain LLC. He also serves as the Medical Director for the Center for Neuroscience, Sleep Disorders Center and Stroke Center at Calvert Memorial Hospital. For more than 25 years, Dr. Kerasidis has studied changes of the electrophysiology of the brain as it relates to behavior, cognitive function and emotional function resulting from various brain trauma, including concussions. His work led to the establishing the first complete concussion management program,

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