Women or girls are up to twice as likely to suffer concussion as their male counterparts when playing the same sports under the same rules, various studies show. They also tend to have more symptoms and take longer to recover.
Yet, so-called “pink” concussion still goes under the radar.
The reasons for higher reported rates among females are believed to be mainly biological, but social factors are also mooted.
A new guide to recognising and managing concussion in grassroots sport, issued by Minister for Public Health Jennifer Murnane O’Connor at the end of March, made no reference to gender differences. It only mentioned children and young people as possibly being at greater risk and taking longer to recover. However, the guidelines, with a core message of “if in doubt, sit them out”, generally apply equally to males and females.
Concussion can be caused by a blow to the head, neck or body and disturbs how the brain works. Common symptoms include headache, dizziness, memory disturbance or balance problems. In only about 10 per cent of cases is there a loss of consciousness.
Much of what is known about concussion comes from male-dominated research. Some 80 per cent of participants in key concussion studies are male, and 40 per cent of studies exclude women, while only 1 per cent of research focuses exclusively on female athletes, according to a review of studies published in the British Journal of Sports Medicine.
The lack of research about women and concussion is one big difference that we can easily change, says US neurologist Dr Beth McQuiston, who has a particular interest in the topic. As medical director of diagnostics at medical device and healthcare company Abbott, she is one of a team that pioneered using a blood sample on a hand-held device to test for concussion, which was included in Time magazine’s “best inventions of 2025”.
When it comes to the biology of concussion, there are three main differences between men and women that we know of, she explains in a video call from her home in Chicago. “Women tend to have less muscular necks. So when an injury occurs, say whether it’s a car accident or if it’s on a pitch, there is less support here,” she says, putting hands up to either side of her neck.
Secondly, there is a difference in the microarchitecture of the brain. Women have more neurons crossing the corpus callosum – a structure in the middle of the brain that connects the right and left hemispheres – and they are thinner.
US neurologist Dr Beth McQuiston
A third factor is the menstrual cycle. “Given the same woman at a different time, exact same injury, there can be a different outcome, depending on whether progesterone levels are high or low. It is worse if it is in the luteal phase [ie after ovulation, approximately days 15-28 of a 28-day cycle], when the progesterone levels are high and then all of a sudden they drop abruptly.” This is due to the effect of the trauma on the pituitary gland, right in the centre of the head.
“That is very intriguing,” says McQuiston. “We’re looking at studies right now, [asking] can someone be on a certain type of oral contraception, or can they take a certain kind of medication, to attenuate that drop if they had a concussion?”
Research indicates women have more post-concussive symptoms and usually take longer to recover. She also highlights a global trend of women’s injuries being more often ignored.
“That can be because of the ‘caretaker response’: what happens when the person that takes care of the family needs to be taken care of?”
Although women are generally more likely to seek medical advice than men, there is a flip side of some who are playing what were traditionally men’s sports – eg rugby, soccer, boxing – not wanting to be seen as weak. Or maybe they don’t have time for health check-up, she suggests, due to caring responsibilities “and they just press forward”.
Although concussion tends to be linked in people’s minds with sports, 97 per cent of all concussions happen to non-athletes, says McQuiston, whose great-grandparents were Murphys from Muskerry in Co Cork. “The number one cause is gravity; the number one age group is 65 and up, and that is predominantly the age of falls.”
Identification of concussion is generally done through observation and asking an individual questions to establish clarity of mind. For further assessment, a CAT scan of the head may be done. However, the problem is, she says, that in the case of mild concussion the scan will likely come back negative. “That doesn’t mean you didn’t have a brain injury. It just means that you don’t have any blood in there or a fracture.”
For more than a decade, she and colleagues have worked to produce a test for biomarkers of brain trauma in the blood, on a device that would provide rapid, lab-standard results at a bedside, pitchside – or in the combat field. The test, which was launched last November and is currently being trialled at the Royal Victoria Hospital, Belfast, has its origins in an approach from the US Department of Defense Technology in 2011, as McQuiston explains.
The military wanted a company to take the fruits of a decade of scientific research into measuring two brain proteins down to picogram level and design a test that would do this, using two drops of blood, on a hand-held device
“Let me just frame this for you: one picogram is the amount of weight of DNA in one hummingbird cell,” she says. “It was obviously a very tall order.” But it was achieved after several years of preparatory work and then seven years of research collaboration involving 300 scientists.
Put very simply, brain protein should remain in the brain and not be seen at significant levels in the peripheral blood circulating around the rest of the body. She likens the concept to that of a piñata – the harder it is hit, the more sweets fall out.
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Testing for two specific brain proteins, GFAP and UCH-L1, in a blood sample is an objective way to measure for possible damage. The test on the i‑STAT Alinity analyser gives results in 15 minutes and can be used up to 24 hours after injury.
As a triage tool, it aids clinicians in deciding when damage to brain tissue is unlikely. This helps to reduce unnecessary CAT scans, by up to 40 per cent in some studies.
Such blood tests are part of a proposed new framework for classifying traumatic brain injury. Currently, in the immediate aftermath of incidents, a system known as the Glasgow Coma Scale is used to group brain injuries into mild, moderate and severe.
A new system for more accurate diagnoses and better treatments has been designed through international collaboration, as reported by The Lancet Neurology last year, and is being evaluated in trials. CBI-M combines clinical assessment, blood markers, imaging (ie brain scans) and modifiers (ie personal factors such as medical history and mental health conditions).
Aside from identification, McQuiston stresses the importance of trying to avoid a first concussion. “After you have one concussion, you’re more vulnerable to getting repeat concussions.”
A good night’s sleep is her number one prevention tip.
“When you don’t get enough sleep, your reaction time is off. Your critical thinking is off. All of these little micro things that you’re not paying attention to are not optimised.”