Migraine and other headache disorders are particularly important when considering concussion in girls and women. Migraine occurs approximately three to four times more often in women than in men after puberty, and women also tend to experience greater migraine-related disability and, in some studies, more severe attacks (Al-Hassany et al., 2020). This underlying vulnerability to headache is clinically relevant because headache is one of the most frequent symptoms following concussion, and a pre-injury history of migraine or recurrent headache can complicate the post-concussion course. When I first wrote about this issue in 2018, I had observed in my Massachusetts practice that recurring headaches seemed more common and sometimes more persistent among the females I treated following concussion (Sefton, 2018). Subsequent research has provided increasing support for paying close attention to sex differences in symptom presentation and recovery.

“Post traumatic headaches are seriously debilitating in terms of lost school and work days. They are often a late symptom in the recovery from brain injury and concussion” Michael Sefton, 2018

The epidemiological picture was already changing substantially at that time. CDC surveillance data showed that the rate of traumatic brain injury-related emergency department visits among females increased from 349.3 per 100,000 population in 2001 to 633.7 per 100,000 in 2010—an increase of approximately 81% (National Center for Injury Prevention and Control, 2019). This increase almost certainly reflected several influences, including greater recognition and appreciation of the risks of concussion, changes in referral and emergency-department utilization, and growing public awareness in youth sports. It should therefore not be interpreted simply as evidence that the biological incidence of concussion in women nearly doubled. Nevertheless, it helped draw attention to a population that historically had been underrepresented in concussion research.

My clinical impression in 2018 was also that some female athletes appeared to have a longer recovery course than comparable male athletes. The research published since then generally supports taking that observation seriously, although the picture is more nuanced than simply saying that every female athlete recovers more slowly. A systematic review by McGroarty et al. (2020) concluded that female athletes may experience greater symptom burden and more prolonged symptoms after sport-related concussion. More recent evidence continues to identify sex-related differences in symptom burden, pain, vestibular-ocular functioning, and some aspects of return to activity (Arachchi et al., 2026). At the same time, large studies have found considerable overlap between male and female recovery trajectories, and initial symptom severity remains one of the strongest predictors of recovery duration. Thus, female gender should be viewed as a potentially relevant clinical factor rather than as a predetermined recovery timetable.

There are several possible contributors to these differences. Pre-existing migraine is more common among females; hormonal influences may affect migraine susceptibility and possibly post-concussion symptom expression; biomechanical differences involving neck strength and head acceleration have been proposed; and males and females may differ in how symptoms are recognized and reported (Al-Hassany et al., 2020; McGroarty et al., 2020). These mechanisms remain areas of active investigation. The practical implication is more straightforward: clinicians should evaluate the individual athlete rather than assuming that recovery will follow a fixed number of days. A girl or woman who continues to experience headache, dizziness, visual disturbance, cognitive fatigue, or other concussion-related symptoms requires continued clinical management rather than pressure to return because an arbitrary recovery period has elapsed.

I also commented in 2018 on alcohol use among some of the males I treated. Alcohol should always be considered – especially in college athletes. Alcohol use is better considered an independent recovery variable rather than a male-specific feature of concussion. Alcohol can impair sleep, judgment, balance, reaction time, and behavioral regulation—all functions that may already be temporarily compromised following concussion. More importantly, subsequent prospective research involving NCAA athletes found that those who reported drinking alcohol after concussion took significantly longer to receive clearance for unrestricted play than athletes who did not report post-injury alcohol consumption (Chang et al., 2024). Alcohol use therefore represents a potentially modifiable factor that clinicians should discuss with all patients recovering from concussion.

Taken together, the research published since my original 2018 CAMP post reinforces an important principle: concussion recovery is individualized. Biological sex, migraine history, initial symptom burden, previous concussion, sleep, emotional functioning, vestibular and cervical symptoms, alcohol use, and premature return to activity can all influence the trajectory toward baseline. Girls and women deserve particular attention because persistent headache and other symptoms may be more prominent in some patients, but clinical decisions should ultimately be based on the person’s actual recovery rather than sex alone. Most importantly, an athlete who remains symptomatic should not return to contact or collision play simply because an expected period of recovery has passed.

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References

Al-Hassany, L., Haas, J., Piccininni, M., Kurth, T., Maassen Van Den Brink, A., & Rohmann, J. L. (2020). Giving researchers a headache—Sex and gender differences in migraine. Frontiers in Neurology, 11, 549038. https://doi.org/10.3389/fneur.2020.549038

Arachchi, S., Daly, E., Dwivedi, A., & Ryan, L. (2026). Sex differences in severity and recovery following mild traumatic brain injury: A systematic review. Brain Sciences, 16(1), 77. https://doi.org/10.3390/brainsci16010077

Chang, R. C., Singleton, M., Chrisman, S. P. D., Giza, C. C., Cuneo, A. Z., Murinova, N., Broglio, S. P., McCrea, M., McAllister, T. W., Sharma, T. L., & CARE Consortium Investigators. (2024). Postinjury alcohol use is associated with prolonged recovery after concussion in NCAA athletes. Clinical Journal of Sport Medicine, 34(1), 30–37. https://doi.org/10.1097/JSM.0000000000001165

McGroarty, N. K., Brown, S. M., & Mulcahey, M. K. (2020). Sport-related concussion in female athletes: A systematic review. Orthopaedic Journal of Sports Medicine, 8(7), 2325967120932306. https://doi.org/10.1177/2325967120932306

National Center for Injury Prevention and Control. (2019). Surveillance of traumatic brain injury-related emergency department visits, hospitalizations, and deaths—United States, 2001–2010. Centers for Disease Control and Prevention.

Sefton, M. (2018, March 14). TBI, concussion and headaches in females. Concussion Assessment and Management Program. https://concussionassessment.wordpress.com/2018/03/14/tbi-concussion-and-headaches-in-females/