INTRODUCTION

Player brain health is a key focus within FIFA Medical. Our vision is that anyone can participate in football without concern for their current or future brain health. To achieve our vision, our initiatives are prioritised towards projects that:

1. Raise awareness, and reduce the risk of sustaining an acute brain/head injury in football (preparation),

2. Improve the identification and management of acute brain/head injuries in football (participation), and/or,

3. Explore the risk between headers, head impacts, and head injuries, and long-term brain health (post-football)

While there is much work to be completed within brain health in football, FIFA Medical have made significant in-roads within the last 4 years. A summary of past, current, and future brain health projects is provided below.

PREPARATION

Suspect and Protect

In 2024, in collaboration with the World Health Organisation (WHO), FIFA launched the Suspect and Protect campaign¹. Developed through extensive consultation with FIFA Medical and WHO brain health experts, the Suspect and Protect campaign aims to increase sign and symptom recognition among players, coaches and medical staff, as well as the general public. The campaign also offers guidance on how to return to play safely following a suspected or confirmed concussion. The tailored resources, translated into multiple languages, and freely available via FIFA’s website (https://inside.fifa.com/campaigns/concussion/toolkit), are designed to empower national team stakeholders, professional clubs and leagues and grassroots and amateur communities.1 Internal data indicates that there have been more than 835 million campaign views, with over 570 member association toolkits downloaded across 115 countries.

Concussion knowledge and education

By surveying medical staff² players, coaching, and performance staff³, and referees⁴ we have been able to gain insight into the current concussion knowledge base across multiple stakeholder groups to inform future education and training. For example, while 75% of referees demonstrated good concussion knowledge, only half perceived their level of knowledge as appropriate, with 95% interested in further concussion education⁴.  A collaborative PhD project in this area is planned with a research team in Portugal.

Head injury prevention

In our collaborative research^5–11 we are exploring the factors that are associated with head impact events in football, beach soccer, and futsal. For example, while player-to-player contact during an aerial duel is the most common head impact mechanism in both men and women^6,7, women are more likely to be injured by the ball, particularly from headers⁷, which is rarely observed in professional men’s football^6,9. Furthermore, the bicycle kick contributes a much higher risk of head injury in beach soccer, with unintentional ball-to-head impacts posing a higher risk in futsal⁵. These insights provide the framework to explore how the role of tactics and technique might contribute to head injury prevention, using a strategy that could be embedded into the coaching of heading⁸.

Heading technique and performance

Heading is a complex skill that involves much more than head-to-ball contact. Given the associated risks of player-to-player contact during a contested header, as well as the risks associated with poor header technique, we have developed a program of research related to understanding contextual factors associated with header incidence^12,13, as well as exploring technical differences in heading between men and women¹⁴. Our findings have shown that international women’s football players are more likely to perform less controlled headers, close their eyes earlier before a header, and use less protective body positioning, when compared with a similar sample of international men’s football players¹⁴. These findings, combined with explorative research to explore the existence and content of heading guidelines (Teahan et al. submitted for publication), and coaching resources (Wright et al. submitted for publication) across FIFA member associations as well as a systematic review on the descriptors, definitions, and outcomes measures used to assess header technique and performance¹⁵, are being used to design future frameworks to support player skill development as part of another PhD project, and other initiatives, including implementation of a preparatory framework for heading, HeaderPrep¹⁶.

PARTICIPATION

Football specific on-pitch concussion assessment protocol

The on-pitch assessment of concussion in football remains challenging due to the absence of a standardised, evidence-based on-pitch assessment protocol, specifically tailored to football. To address this critical gap, a project steering committee comprising of 3 members of FIFA Medical, along with 13 representatives from each of the 6 regional confederations, and 3 independent experts with expertise in injury spotting (concussion) for FIFA-tournaments (n=1),  and research methodology to ensure optimal quality of the scientific process (n=2), was convened. The purpose of this steering committee is to oversee and facilitate the process to create an evidence-informed football-specific standardised tool for the on-pitch assessment of concussion. Through a combination of a systematic review (Connolly et al. under review), to identify and synthesise the evidence on the diagnostic accuracy of any item/tool used to assess suspected concussion at the time of injury with a key focus on football, and an international Delphi process, 45 items were identified and incorporated into the Football-specific On-pitch concussion assessment protocol (FOCUS). FOCUS is currently being pilot tested in the OFC Pro League, with an implementation and evaluation phases to assess the diagnostic test accuracy of FOCUS due to commence later in 2026.

Concussion substitution trial

Following approval at the 138th Annual General Meeting (AGM) of The International Football Association Board on 2nd March 2024, the Laws of the Game now allow competitions to permit the use of additional permanent concussion substitutions¹⁷.An additional permanent concussion substitution occurs when a player who has an actual or suspected concussion is substituted and takes no further part  in the match. This substitution does not count as one of the ‘normal’ permitted substitutions (or substitution opportunities)¹⁷. This decision was made following the completion of a global permanent concussion substitution trial from January 2021 to July 2024 (Serner et al. under review). This trial included 40826 matches from 278 competition editions. Summary data from the trial reported a total of 833 concussion incidents (incidence rate 0.62 per 1000 match hours), in which a concussion substitution was used in 750 incidents (90.7%), while a normal substitution was used in 38 incidents (4.6%). Thirty-five incidents (4.2%) did not result in a player substitution. Further, the proportion of concussion substitutions used was similar between women’s and men’s competitions.  Of the 614 incidents with diagnostic information, a confirmed diagnosis of concussion was reported in 462 players, with 91.8% (n=424) being substituted during the match. Most concussion substitutions (n=562, 81.2%) occurred immediately after the incident, whereas 18.8% (n=130) occurred after return to play (with the median time after returning to play being 11 minutes; IQR, 5–24). These findings support the use of an additional concussion substitution in football with potential benefit for player health across diverse competition contexts globally.

Injury spotters

Injury spotters were first introduced in the FIFA Arab Cup in 2021¹⁸. Since then injury spotters have been used in over 12 different FIFA organised tournaments including the FIFA World Cup 2022,  FIFA Women’s World Cup 2023, 2024 Olympic Games, and men’s and women’s Under-17, and Under-20 World Cups. The role of the injury spotter is to alert the FIFA match doctor if a potentially injurious head impact has been observed, as well as the presence (or absence) of any visible signs of concussion to assist the team doctors in their on-pitch assessment of the involved player. The FIFA injury spotter video review process is informed by the scientific literature¹⁹, FIFA Medical’s experience in implementing the injury spotter program at FIFA tournaments^18,20, as well as insight provided by experts who have implemented injury spotters in football or other contact sports.  FIFA's Injury Spotter Manual (available here: digitalhub.fifa.com/m/24832ef45a1fc759/original/Injury-spotter-manual-General.pdf) details the visible signs of concussion that injury spotters are trained to observe, categorised as red and yellow flags. Red flags include tonic posturing, motor incoordination, no protective action during fall (floppiness), impact seizure/convulsion and visible signs of potential concussion after return to play, following a medical assessment. Yellow flags include blank/vacant look, lying motionless, disorientation, concerning mechanism of injury (high force impact, dual head impact), face or scalp bleeding, and visible signs of potential concussion after return to play without a medical assessment. The presence of one or more red flags indicates that the player has likely sustained a concussion and should be immediately substituted regardless of medical assessment findings, while the presence of one or more yellow flags indicates the need for clinical assessment (if one has not yet been conducted). Injury spotters are now embedded in FIFA Medical competition procedures, with current projects being conducted to formalize the education process, as well as explore the diagnostic test accuracy of red and yellow flags in identifying players with concussion during match play. Throughout this period FIFA has worked with different setups with the assistance of our innovation department, including spotters directly at the stadium, a centralized setup from one location for a tournament, and with complete remote spotters which can be done from a different corner of the world. Beyond the dedicated spotters, the guidance related to visible signs are intended to be useful for anyone with access to video footage of a head impact.

Ethical considerations in return to play following a concussion

In partnership with researchers from Centre for Biomedical Ethics and Law, KU Leuven, Belgium, and the Department of Sport and Social Sciences, Norwegian School of Sport Sciences, Norway, we have been investigating how return-to-play following a concussion is currently managed across FIFA’s Member Associations globally²¹. The findings from this project indicate that while a significant number of FIFA member associations were found to have concussion guidelines that closely aligned with international guidance, substantial variability was identified in relation to initial rest periods, stage progression criteria, timing of return to play, medical clearance, and symptom management²¹. Limited accessibility and availability of concussion documents and return to play protocols was also noted, representing a critical global challenge in concussion management in football²¹. These gaps, coupled with the health implications of sport-related concussions, underscore the need for coherent, evidence-based, and ethically grounded approaches that ensure player safety while allowing for contextual flexibility in football medicine²¹. Further research has also been completed to investigate the underlying rationale and real-world implementation of existing return to play protocols, as well as the factors driving the observed differences across member associations through clinician and other stakeholder interviews²¹.

Action spotting of header Incidence

In conjunction with FIFA Innovation, and led by research partners in Saudi Arabia, and Belgium, a program of research has been developed using cutting-edge computer vision techniques to identify headers in FIFA World Cup matches from the 1990s to present day²². To support this project King Abdullah University of Science and Technology have become the first FIFA Research Institute in the Middle East (and fifth globally). Together this project will drive research-led innovation to automate and dramatically reduce the current labour intensive task of video identification of headers during match play, as a way to track longitudinal header exposure, and continue to support the technical evolution of football.

POST-FOOTBALL

Heading in Football Research database

In 2024 FIFA Medical in conjunction with FIFA’s Heading Expert Group created a Heading in Football Research Database with plans that this will become an open-source, living index and summary of all the published research on heading. The Terms of Reference for the FIFA Heading Expert Group states: “The purpose of this expert group is to ensure that the most up to date research findings related to heading in football are available to all football stakeholders.” To meet this purpose, each member of FIFA’s Heading Expert Group is currently leading or supervising one or more systematic reviews which summarises the evidence related to the following topic areas:

1. Header incidence or load

2. Heading as a mechanism of acute head/brain injury

3. Non-human/theoretical/mathematical research

4. Head impact magnitude

5. Short-term effects of headers (one session)

6. Medium-term effects of headers (>one session in active players)

7. Long-term effects of headers (retired players)

8. Heading technique and performance

9. Risk mitigation strategies

The Heading in Football Research database documents every original research study that was located through database searching that included headers, ball-to-head impacts, and heading as an outcome measure. The first databases searches were completed in May 2024, with updates every six months, leading to the most recent database searches being completed on 3rd February 2026. This has resulted in 483 individual research studies being included in the database. The findings from these 9 systematic reviews are due later this year with the intention that the risk posed through headers in terms of short-, and long-term brain health, as well as the strategies that could be implemented to reduce risk will be more fully understood, while also highlighting where the continuing gaps in research knowledge remain to inform future research priorities.

Football Research Quality

Maintaining research excellence through the development of standardised descriptors and definitions used in football research is another FIFA Medical priority. This includes the development of a medical extension to the FIFA Football Language²³.  The aim of the FIFA Football language is to better understand the development of the game from a performance analysis perspective, with the medical extension being applied to better understand the context of injury inciting events more broadly¹⁰, as well as head injuries more specifically⁹.

An international consensus project was completed in 2025 to create a standardised framework of descriptors, definitions, and reporting methods for heading in football research²⁴. This process was informed by a systematic review where it was reported that  from 71 included studies, only 23% included an operational definition of a header in the methods of their paper, with 39% not defining a header at all²⁵. In addition, four studies explicitly stated or implied in the methods that any ball-to-head contact was recorded as a header with a further five studies reporting ball-to-head impact data in the results without distinction²⁵. There was also a lack of standardisation in the reporting methods used in these header incidence studies, with only 15% of included studies reporting header incidence per 1000 match or practice hours, meaning comparing data between studies is challenging²⁵. The international consensus project involved 167 participants from diverse football-related backgrounds including coaches, players, medical personnel, and researchers, and resulted in 27 descriptors being recommended for inclusion in minimum reporting criteria for heading in football research²⁴. With an additional 27 descriptors also being defined for inclusion in an expanded framework. Most importantly the operational definition of a header was standardised as “a head-to-ball contact where the player makes a deliberate movement to redirect the trajectory of the ball using their head.”²⁴ Heading was also defined “as a player performing a deliberate movement to redirect the trajectory of a ball using their head. Therefore, heading could result in either a header (with head-to-ball contact) or an attempted header (without head-to-ball contact) and could be performed in either a contested (duel) or uncontested (no duel) situation.”²⁴ These definitions enable a clear distinction between the head-to-ball contact (i.e. the header), and the broader actions required to complete the header (i.e. heading), which is particularly important when assessing the risk of head injury associated with different mechanisms, vital for informing injury prevention initiatives.

CONCLUSION

FIFA Medical is advancing a global, evidence based strategy to protect player brain health across all stages of the game. Key initiatives include international education campaigns, research driven head injury prevention, improved on pitch concussion assessment, and large scale trials supporting safer removal from play, and return to play decisions. New technologies are being explored to track header exposure. While the Heading in Football Research Database and international consensus frameworks strengthen research quality and consistency, as well as providing continuously updated insights in the development of evidence that can influence future initiatives. In this process FIFA is involving multiple stakeholders, including confederations, member associations, independent researchers, coaches and players,  with and open and inclusive approach ensuring diversity in expertise, opinions., and contexts. Together, these coordinated efforts aim to reduce head injury risk, enhance clinical decision making, and build a safer football environment now and for the future.

Kerry Peek PhD

PhD (Behavioural Science), M Clin Sci (Evidence-Based Practice), Post-Grad Cert (Sports Physiotherapy), BSc (Hons) Physiotherapy

FIFA Medical Researcher, Brain Health

Andreas Serner PhD

PhD (Clinical Research), MSc (Medical Sciences), BSc Physiotherapy

FIFA Lead Research

Andy Massey

MB BCh BAO MSc(Sports Medicine) MSc(Medical Ultrasound) MSc(Sports Physiotherapy) BSc(Hons)(Physiotherapy) MRCGP FFSEM(UK) FFSEM(Ire) FFMLM

FIFA Medical Director

Chair FIFA Medical Committee

FIFA Medical, Fédération Internationale de Football Association

Zurich, Switzerland

Contact: kerry.peek@fifa.org

References

1.             FIFA. Concussion: Suspect and Protect. 2024. Accessed March 5, 2025. https://inside.fifa.com/campaigns/concussion

2.             Wilke CF, Serner A, Massey A, et al. Knowledge, attitude, and behaviour around concussion at the FIFA Women’s World Cup 2023: part 1-medical staff. Sci Med Footb. 2025;9(3):251-261.

3.             Wilke CF, Serner A, Massey A, et al. Knowledge, attitude and behaviour around concussion at the FIFA Women’s World Cup 2023: part 2–coaches, performance staff and players. Sci Med Footb. 2025;9(3):262-274.

4.             Rosenbloom C, Massey A, Kryger KO, Serner A, Peek K, Carmody S. Professional referees’ knowledge of the FIFA Medical Concussion Protocol and their experiences with concussions during match-play. J Sci Med Sport. doi:10.1016/j.jsams.2026.01.002

5.             Lima Y, Yoruk I, Gouttebarge V, Bayraktar B. Head Injuries and Correlates in Beach Soccer: Video-Based Analysis of Five Consecutive Seasons. Am J Phys Med Rehabil. Published online 2025. doi:10.1097/PHM.0000000000002712

6.             Lima Y, Karaçoban L, Serner A, Peek K, Köyağasıoğlu O. Potential head injuries in men’s football, futsal and beach soccer: Distinct exposure‐adjusted frequency and patterns from a comparative video analysis. Knee Surg Sports Traumatol Arthrosc. Published online 2025.

7.             Lima Y, Köyağasıoğlu O, Karaçoban L, Serner A, Peek K. Potential head injuries in professional women’s football: A video analysis of frequency, characteristics, and assessment. J Sci Med Sport. Published online 2025.

8.             Peek, K, Georgieva, J, Wilson, B, Massey, A, Serner, A. Re-thinking head injury prevention in football: The role of tactics and technique. J Sci Med Sport. Published online 2025.

9.             Peek K, Aiello F, Avery L, et al. Characteristics of potential head injury situations at the FIFA World Cup Qatar 2022TM. Sci Med Footb. Published online 2024:1-9.

10.Aiello F, Avery L, Gardner T, et al. Broadening our understanding of injury mechanisms to include at-risk situations: an overview of potential injuries at the FIFA men’s world cup Qatar 2022TM. Sci Med Footb. Published online 2024:1-10.

11.           Sarkohi A, Hovenberg A, Hagglund M, Serner A, Peek K. Incidence of Head Contact Events Including Headers, and Potential Head Injuries at the FIFA Futsal World Cup Lithuania 2021. Scand J Med Sci Sports. 2025;35(6):e70083. doi:10.1111/sms.70083

12.           Georgieva J, Peek K, Smith A, et al. Heading performance outcomes at the FIFA Women’s World Cup France 2019TM. Int J Sports Sci Coach. Published online 2024:17479541241298757.

13.           Georgieva J, Arnold EJ, Peek K, et al. The incidence and characteristics of heading in the 2019 FIFA Women’s World CupTM. Sci Med Footb. 2025;9(2):104-111.

14.           Peek K, Georgieva J, Serner A, Orest F. Differences in the technical performance of heading between men and women football players during FIFA World Cup 2022 and FIFA Women’s World Cup 2023 matches. BMJ Open Sport Exerc Med. 2024;10(3):e002066.

15.           Cairns R, McKay MJ, Serner A, Peek K. Descriptors and definitions of heading technique and performance in football: A systematic review. J Sci Med Sport. 2026;published online.

16.           Ross AG, Whalan M, Duffield R, Peek K. Can we prepare young female players for heading in football? The feasibility and acceptability of HeaderPrep. J Sci Med Sport. Published online 2025.

17.           The International Football Association Board. Laws of the Game 25/26. Published online July 1, 2025. https://downloads.theifab.com/downloads/laws-of-the-game-2025-26-single-pages?l=en

18.           Serner A, Araújo J, Beasley I, et al. Video review of the frequency and assessment of head impacts during the FIFA Arab Cup 2021TM. Sci Med Footb. 2023;7(4):331-336.

19.           Davis GA, Makdissi M, Bloomfield P, et al. International consensus definitions of video signs of concussion in professional sports. Br J Sports Med. 2019;53(20):1264-1267.

20.Serner A, Putukian M, Echemendia R, Massey A, Sherry K. Visible signs of possible concussion at the FIFA world cup Qatar 2022TM: independent review and inter-rater reliability. J Sci Med Sport. Published online 2025.

21.           Sesa G, Borry P, Loland S, et al. Managing concussions in football: a review of football associations’ return-to-play guidance. J Sci Med Sport. Published online 2026.

22.Giancola S, Cioppa A, Georgieva J, et al. Towards active learning for action spotting in association football videos. In: 2023:5098-5108.

23.FIFA. The FIFA Football Language. FIFA Training Centre. November 24, 2022. Accessed March 4, 2025. https://www.fifatrainingcentre.com/en/game/performance-analysis/football-language-analysis/the-fifa-football-language.php

24.Peek K, Ross AG, Williamson PR, et al. Consensus on the descriptors, definitions, and reporting methods for heading in football studies: A Delphi study. PLoS One. Published online 2025.

25.Peek K, Ross A, Andersen TE, et al. Heading in football: a systematic review of descriptors, definitions, and reporting methods used in heading incidence studies. Sci Med Footb. Published online 2024:1-18.

Header Image by Agência Brasília (Cropped)