ORIGINAL RESEARCH| Volume 102, ISSUE 12, P2369-2376, December 2021

Reference Values for the Headache Impact Test-6 Questionnaire



      To determine reference values for the Headache Impact Test-6 (HIT-6) in a young, physically active cohort and to examine the influence of sex, concussion history, headache history, and competitive sport level on HIT-6 scores.




      United States Service Academy.


      United States Service Academy cadets (N=2678) completed an HIT-6 questionnaire as part of their annual concussion baseline assessment. Cadets with a recent concussion were excluded from baseline testing.


      Not applicable.

      Main Outcome Measures

      Reference values were calculated and stratified by sex, concussion history, headache history, and competitive sport level. Mann-Whitney U and Kruskal-Wallis tests were used to examine the effect of sex, concussion history, headache history, and competitive sport level on HIT-6 scores (P<.05).


      Of the 3599 cadets baselined, 2687 cadets (23% female) agreed to participate in the study and completed the HIT-6. Female participants reported significantly worse HIT-6 scores compared with male participants both with (P<.001) and without (P<.001) a concussion history. In both sexes, participants with a headache history reported worse scores than those with no headache/concussion history and a concussion history (all P<.005). Female cadets who participated in intramural athletics reported worse HIT-6 scores at baseline than female intercollegiate athletes (P=.003).


      This is the first study to stratify HIT-6 data by sex, concussion history, headache history, and sport level in a collegiate population at risk for concussions. Sex and headache history appear to influence HIT-6 scores and should be given special consideration when interpreting health-related quality of life deficits due to headache.


      List of abbreviations:

      HIT-6 (Headache Impact Test-6), HRQL (health-related quality of life), NCAA (National Collegiate Athletic Association)
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        • Veliz P
        • McCabe SE
        • Eckner JT
        • Schulenberg JE.
        Prevalence of concussion among US adolescents and correlated factors.
        JAMA. 2017; 318: 1180-1182
        • Houck Z
        • Asken B
        • Bauer R
        • et al.
        Epidemiology of sport-related concussion in an NCAA Division I Football Bowl Subdivision sample.
        Am J Sports Med. 2016; 44: 2269-2275
        • Hoge CW
        • McGurk D
        • Thomas JL
        • et al.
        Mild traumatic brain injury in US soldiers returning from Iraq.
        N Engl J Med. 2008; 358: 453-463
        • Hoge CW
        • Goldberg HM
        • Castro CA.
        Care of war veterans with mild traumatic brain injury—flawed perspectives.
        N Engl J Med. 2009; 360: 1588-1591
        • Hendricks AM
        • Amara J
        • Baker E
        • et al.
        Screening for mild traumatic brain injury in OEF-OIF deployed US military: an empirical assessment of VHA's experience.
        Brain Inj. 2013; 27: 125-134
        • McCrory P
        • Meeuwisse W
        • Dvorak J
        • et al.
        Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016.
        Br J Sports Med. 2017; 51: 838-847
        • O'Connor KL
        • Baker MM
        • Dalton SL
        • et al.
        Epidemiology of sport-related concussions in high school athletes: National Athletic Treatment, Injury and Outcomes Network (NATION), 2011-2012 through 2013-2014.
        J Athl Train. 2017; 52: 175-185
        • Makdissi M
        • Darby D
        • Maruff P
        • et al.
        Natural history of concussion in sport: markers of severity and implications for management.
        Am J Sports Med. 2010; 38: 464-471
        • Castile L
        • Collins CL
        • McIlvain NM
        • Comstock RD.
        The epidemiology of new versus recurrent sports concussions among high school athletes, 2005-2010.
        Br J Sports Med. 2012; 46: 603-610
        • Weber M
        • Lynall R
        • Hoffman N
        • et al.
        Health-related quality of life following concussion in collegiate student-athletes with and without concussion history.
        Ann Biomed Eng. 2019; 47: 2136-2146
        • Fineblit S
        • Selci E
        • Loewen H
        • Ellis M
        • Russell K.
        Health-related quality of life after pediatric mild traumatic brain injury/concussion: a systematic review.
        J Neurotrauma. 2016; 33: 1561-1568
        • Hoffman JM
        • Lucas S
        • Dikmen S
        • et al.
        Natural history of headache after traumatic brain injury.
        J Neurotrauma. 2011; 28: 1719-1725
        • Kosinski M
        • Bayliss M
        • Bjorner J
        • et al.
        A six-item short-form survey for measuring headache impact: The HIT-6™.
        Qual Life Res. 2003; 12: 963-974
        • Valovich McLeod TC
        • Bay RC
        • Snyder AR
        Self-reported history of concussion affects health-related quality of life in adolescent athletes.
        Athl Train Sports Health Care. 2010; 2: 219-226
        • Kuehl MD
        • Snyder AR
        • Erickson SE
        • Valovich McLeod TC
        Impact of prior concussions on health-related quality of life in collegiate athletes.
        Clin J Sport Med. 2010; 20: 86-91
        • Brown DA
        • Elsass JA
        • Miller AJ
        • Reed LE
        • Reneker JC.
        Differences in symptom reporting between males and females at baseline and after a sports-related concussion: a systematic review and meta-analysis.
        Sports Med. 2015; 45: 1027-1040
        • Anokye NK
        • Trueman P
        • Green C
        • Pavey TG
        • Taylor RS.
        Physical activity and health related quality of life.
        BMC Public Health. 2012; 12: 1-8
        • O'Connor PJ
        Normative data: their definition, interpretation, and importance for primary care physicians.
        Fam Med. 1990; 22: 307-311
        • Broglio SP
        • McCrea M
        • McAllister T
        • et al.
        A national study on the effects of concussion in collegiate athletes and US Military Service Academy members: the NCAA-DoD Concussion Assessment, Research and Education (CARE) Consortium Structure and Methods.
        Sports Med. 2017; 47: 1437-1451
        • Yang M
        • Rendas-Baum R
        • Varon SF
        • Kosinski M.
        Validation of the Headache Impact Test (HIT-6™) across episodic and chronic migraine.
        Cephalalgia. 2011; 31: 357-367
        • Piebes SK
        • Snyder AR
        • Bay RC
        • Valovich McLeod TC
        Measurement properties of headache-specific outcomes scales in adolescent athletes.
        J Sport Rehabil. 2011; 20: 129-142
        • Kawata AK
        • Coeytaux RR
        • DeVellis RF
        • et al.
        Psychometric properties of the HIT-6 among patients in a headache-specialty practice.
        Headache. 2005; 45: 638-643
        • Bayliss M
        • Batenhorst AJL
        The HIT-6TM a user’s guide.
        QualityMetric, Lincoln2002
        • Fritz CO
        • Morris PE
        • Richler JJ.
        Effect size estimates: current use, calculations, and interpretation.
        J Exp Psychol Gen. 2012; 141: 2-18
        • Smelt AF
        • Assendelft WJ
        • Terwee CB
        • Ferrari MD
        • Blom JW.
        What is a clinically relevant change on the HIT-6 questionnaire? An estimation in a primary-care population of migraine patients.
        Cephalagia. 2014; 34: 29-36
        • Cohen J.
        Statistical power analysis for the behavioral sciences.
        2nd ed. Lawrence Erlbaum Associates, Hillsdale1988
        • Delaruelle Z
        • Ivanova TA
        • Khan S
        • et al.
        Male and female sex hormones in primary headaches.
        J Headache Pain. 2018; 19: 117
        • Combs PR
        • Ford CB
        • Campbell KR
        • Carneiro KA
        • Mihalik JP.
        Influence of self-reported fatigue and sex on baseline concussion assessment scores.
        Orthop J Sports Med. 2019; 72325967118817515
        • Wallace J
        • Covassin T
        • Beidler E.
        Sex differences in high school athletes' knowledge of sport-related concussion symptoms and reporting behaviors.
        J Athl Train. 2017; 52: 682-688
        • Kerr ZY
        • Register-Mihalik JK
        • Marshall SW
        • et al.
        Disclosure and non-disclosure of concussion and concussion symptoms in athletes: review and application of the socio-ecological framework.
        Brain Inj. 2014; 28: 1009-1021
        • Houston MN
        • Hoch MC
        • Hoch JM.
        Health-related quality of life in athletes: a systematic review with meta-analysis.
        J Athl Train. 2016; 51: 442-453
        • Omorou YA
        • Erpelding ML
        • Escalon H
        • Vuillemin A.
        Contribution of taking part in sport to the association between physical activity and quality of life.
        Qual Life Res. 2013; 22: 2021-2029
        • Caccese JB
        • Iverson GL
        • Hunzinger KJ
        • et al.
        Factors associated with symptom reporting in US Service Academy cadets and NCAA student athletes without concussion: findings from the CARE Consortium.
        Sports Med. 2021; 51: 1087-1105