March 14, 2023 – Jacqueline Theis, a Virginia-based optometrist, was an avid soccer player during her teens. In the course of her athletic career, she had several concussions that triggered severe headaches when she tried to read.
“I was told that I had migraines and I’d ‘get over them’ and that I was ‘complaining too much’ – comments that are unfortunately all too common for women to hear,” she says.
“After 6 years, I saw an optometrist who noticed that my eyes weren’t coordinating and thought this was due to the concussions,” she recounts. “She prescribed glasses and vision therapy, and my headaches went away.”
Theis was angry that her headaches had been minimized and her visual issues overlooked. “I had 20/20 vision, so it didn’t occur to anyone that I could be having eye problems,” she says.
‘Invisible’ and Neglected
Katherine Snedaker, a licensed clinical social worker, agrees that women’s concussions are often minimized or overlooked. She created and leads PINK Concussions, a nonprofit group focused on concussions in women.
She says almost all of the previous concussion research has used male lab animals and men as subjects, although concussions are common in women too. And while people think of concussions in women as being sports-related injuries, PINK Concussions’ mission includes shining a spotlight on accidents, military service injuries, and domestic violence.
Over the past 5 years, “we’ve been able to raise awareness of brain injuries in female athletes and women veterans, but the far greater number of repetitive brain injuries are still hidden and endured by the invisible women who suffer intimate partner violence in every social and economic group of society,” she says.
“Concussions affect women and men differently, so it’s important for clinicians, parents, and others to be aware of how concussions might present in females as well as males,” says Snedaker, who has had multiple concussions, two of which came from car accidents.
David Wang, MD, head team doctor at Quinnipiac University in Hamden, CT, says that when women and men compete in the same sports, women get concussions at higher rates than men. Their symptoms also tend to be more severe, and they often have more prolonged symptoms.
There are several theories as to why women are more vulnerable to concussions and often have more severe symptoms or poorer outcomes, says Wang, who is the director of Comprehensive Sports Medicine in Connecticut.
Some studies suggest that female hormones may play a role. For example, one study found that women at certain phases of their menstrual cycle had worse symptoms after their concussion. And women often notice changes in their menstrual patterns after a concussion.
But Wang believes the story is more complex. “Concussions shake the pituitary gland, which is located in the head,” he says. “The pituitary is responsible for regulating aspects of women’s hormones. Stress to the pituitary – whether due to the mechanical injury of the concussion or to emotional stress that can follow a concussion – may affect the menstrual cycle.”
This is supported by a new study. The researchers screened for hypopituitarism (low hormonal production by the pituitary) in 133 female athletes with a history of traumatic brain injury. The researchers found that the majority of women (66.2%) had abnormal pituitary screening blood test results. Certain hormones were too high, while others that were too low. Younger athletes and those with more symptoms had more pituitary hormone abnormalities.
Neck, Eyes, and Brain
Wang shared several other theories regarding women’s vulnerability to concussions.
“Women in general have weaker necks; and since the neck is weaker, the head accelerates more when it’s hit because the impact is more severe and violent,” he explains. Although this “isn’t the whole story, it is a contributing factor.”
Theis, who is affiliated with the Concussion Care Centre of Virginia, says there’s an “intimate relationship between eye movements, the brainstem, and the neck; and since women have weaker necks, compared to men, their eye movements are going to be more vulnerable to neck-related injuries.”
She says eye problems are also a little-known complication of whiplash as well. “The connection is in the brainstem and the neck.”
She says that the neck may not necessarily be painful, but eye pain or headaches can be “referred” pain from the neck.
Other theories include that women also may have different levels of inflammation, compared to men, Wang says. And concussions often target an area of the brain called the corpus callosum, which connects the right and left hemispheres. “This area receives the majority of the strain from a concussive blow, and that area is more robustly used by women than by men because females tend to use both hemispheres in process more than males do.”
Myths About Women
All the experts agree that there are common myths about the greater frequency of concussions in women and their more severe symptoms.
“Some people think women have more concussions because they complain more about symptoms, so they’re more likely to be diagnosed,” Wang says. “I don’t like to hear that, because it suggests that women are ‘complainers’ and also that female athletes are less competitive than male athletes, which simply isn’t true.”
Wang and his colleagues studied athletes and found that females were at least as likely as males to hide symptoms so as not to be taken out of the game. “In fact, some of the most driven people I’ve ever met are female athletes,” he says.
Snedaker recommends that women take their symptoms seriously. “I’ve spoken to countless women who said their concussion symptoms were dismissed by doctors or were told that they’re simply anxious.” she says.
So if you’ve had a blow to the head and your health care provider doesn’t do a thorough concussion workup, “it’s time to look for a different provider,” Snedaker advises.
Different Symptoms, Different Treatments?
Most of the symptoms of concussion – other than menstrual dysfunction – don’t differ between the sexes, according to Wang. “It’s not like a heart attack, where often, women actually have different symptoms than men – like nausea rather than chest or jaw pain,” he says.
Typical symptoms of concussion in both men and women include headaches, dizziness, blurry vision or other visual disturbances, agitation or cognitive changes, light and sound sensitivity, disorientation, nausea or vomiting, or feeling dazed.
Because concussions can affect the menstrual cycle, Snedaker encourages health care professionals to ask women who have had a concussion about their periods. “If there’s an issue, follow up with endocrine testing,” she recommends. And if you’ve had a concussion and notice changes in your periods, be sure to bring this up to your provider.
Men and women have similar “landmarks” and “rules” for returning to play or to any other activity, such as employment or academics. “We expect them to be without symptoms, and we put them through a graded return to activity,” Wang states.
But since women’s symptoms tend to last longer than those of men, “women need to be supported throughout that time,” Snedaker emphasizes. All too often “women are called ‘malingering’ or ‘mentally ill’ when they don’t recover as fast as men.”