• Neuro Effects of COVID-19
  • Melatonin and Children with Postconcussive Symptoms
  • Pediatric, Sports-Related Concussion
  • Acute Migraine in Children and Adolescents

Emily Montgomery, MD and Kelsey Riggs, MS3

Neurologic Manifestations of COVID-19

Take-home point: COVID-19 has a variety of presentations that include neurologic manifestations—most commonly, headaches.

Citation: Niazkar HR, Zibaee B, Nasimi A, Bahri N. The neurological manifestations of COVID-19: a review article. Neurol Sci. 2020 Jul;41(7):1667-1671.

Relevance: More than 1/3 of patients with COVID-19 experience neurologic manifestations at some time in the disease course. Providers must be familiar with these signs and symptoms in order to ensure timely diagnosis and management.

Study summary: This was a literature review of >40 studies covering neurologic effects of COVID-19. There is a wide range of symptoms—fever, cough, chest pain, rhinorrhea, diarrhea, nausea, vomiting, fatigue, and confusion common among them—relating to all organ systems experienced by patients affected by COVID-19. Neurologic dysfunction is seen in 1/3 of patients with COVID-19 overall, although neurologic symptoms are more common in cases of severe illness. Headache is, by far, the most common CNS manifestation. Other common neurologic symptoms noted include mental status changes /delirium, which are seen most often in older populations. Patients may also experience cerebrovascular events if suffering from severe disease. Other less common CNS manifestations include generalized tonic-clonic seizures, acute necrotizing encephalopathy, ataxia, viral encephalitis, and acute disseminated encephalomyelitis. Some studies suggest that SARS-CoV-2 may directly infect brain stem neurons, leading to disruption in the function of the cardiorespiratory regulation center. This may explain the increased prevalence of CNS manifestation in patients that are severely ill.

The most common peripheral nervous system symptoms are anosmia and dysgeusia. These symptoms, in the current era, are highly specific for COVID-19. It is hypothesized that altered taste and smell is associated with increased ACE-2 receptors on the nasal mucosa and tongue.

Efficacy of Melatonin in Children with Postconcussive Symptoms

Take-home point: Melatonin does not improve postconcussive symptoms in children.

Citation Barlow KM, Brooks BL, Esser MJ, et al. Efficacy of melatonin in children with postconcussive symptoms: a randomized clinical trial. Pediatrics. 2020 Apr;145(4):e20192812.

Relevance: About ¼ of pediatric patients will have postconcussive symptoms following mild traumatic brain injury (mTBI), which can significantly affect quality of life (QOL).

Study summary: Persistent postconcussive symptoms are poorly understood. Melatonin is known to be well tolerated and has shown neuroprotective effects in prior work. This was a randomized, double-blind, placebo-controlled study of 99 children 8 to 18 years of age receiving doses of 3 mg or 10 mg of melatonin or placebo. It was found that administration of melatonin for 4 weeks for postinjury led to no significant difference in postconcussion symptoms compared with placebo. Overall, 78% of patients recovered within 3 months regardless of treatment arm.

Limitations: It is hypothesized that the melatonin may exert effects through modulation of oxidative stress, which peaks 3-5 days after the initial mTBI. Therefore, melatonin may have been administered too late to play a role through this mechanism. Future studies should evaluate whether melatonin administered beginning at the time of injury improves recovery after mTBI.

Sports-Related Concussion in Children

Take-home point: Care for sports-related concussions in young athletes is improved through the use of a multidisciplinary approach.

Citation: Podolak OE, Arbogast KB, Master CL, et al. Pediatric sports-related concussion: an approach to care. Am J Lifestyle Med. January 2021. Available at: https://journals.sagepub.com/doi/10.1177/1559827620984995. Accessed April 14, 2021.


Relevance:
Sports-related concussions are extremely common in children and can result in significant long-term disability; therefore, early recognition and appropriate management are vital.

Study summary: This was a review of literature for pediatric concussions resulting from sports. Following a symptomatic head injury, patients should be immediately removed from play and evaluated. Symptoms often fall into one of five core domains: somatic, visio-vestibular, cognitive, mood, and sleep. It is important to note that many of these symptoms may not be present immediately following the injury. Additionally, young athletes often underreport symptoms in an effort to avoid being removed from play. Emergent imaging is rarely necessary, but should be recommended when a patient experiences loss of consciousness, repeated emesis, progressive/worsening of symptoms, or persistent Glasgow Coma Score (GCS) <15.

Acute management should include assessment for deficits in one or more of the five core domains. Patients should rest completely for at least 24-48 hours following the head injury. Following rest, concussion management should be individualized for each patient. Current recommendations focus on a gradual return to athletics and cognitive tasks/schoolwork. Persistent symptoms may require tailored strategies including aerobic exercise, visual-vestibular therapy, and psychiatry dependent on the patient’s symptoms and deficits. An interdisciplinary team is crucial for such cases where postconcussive symptoms involve multiple domains.

Acute Treatment of Migraine in Pediatric Patients

Take-home point: Management of acute migraine in pediatric patients should focus on early intervention.

Citation: Oskoui M, Pringsheim T, Holler-Managan Y, et al. Practice guideline update summary: acute treatment of migraine in children and adolescents: report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology. 2019;93(11):487-499. Epub August 14, 2019. Erratum in: Neurology. 2020 Jan 7;94(1):50.

Relevance: Migraine is relatively common in children and adolescents, while urgent care is a common destination for pediatric patients with migraine.

Study summary: These are consensus guidelines constructed by experts based on a systematic review of the literature. Treatment for acute migraine in children and adolescents is most effective with early recognition and intervention. Clinician assessment should begin with confirming that the headache presentation is, indeed, consistent with the patient’s migraine.

Migraines are best treated early, with pharmacotherapy initiated while symptoms are still mild. Initial treatment options include ibuprofen and/or acetaminophen with standard weight-based dosing. Depending on the patient’s age, specific triptans may be used if NSAIDs are not providing adequate relief. Triptans seem to be more effective for treating associated photophobia and phonophobia. Associated nausea and vomiting are best treated with antiemetics, as migraine-directed analgesics tend to treat nausea poorly. Nausea should also be considered when considering route of administration.

It is important, especially for pediatric patients and their caregivers, to identify and avoid migraine triggers. Overreliance on any migraine medication, including ibuprofen and acetaminophen, can result in overuse headaches.

Limitations: Studies on migraine treatment in children are not as common as those focused on adults; therefore, the recommendations are based on less and lower quality evidence.

Emily Montgomery, MD practices at Children’s Mercy Hospital in Kansas City, MO and is Clinical Assistant Professor of Pediatrics, University of Missouri-Kansas City School of Medicine and Clinical Assistant Professor of Pediatrics, University of Kansas School of Medicine. Kelsey Riggs, MS3 is a third-year student at the University of Kansas School of Medicine.

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