American jockey Mike Smith knows the feeling. A headache. Maybe some dizziness.

As a younger jockey he got concussions, felt better and went back to riding.

“I’ve had several,” Smith said. “It’s just like you hit your head playing any sport.”

Smith is currently in the international spotlight after his recent Triple Crown win aboard Justify in the Belmont, but he’s far from alone as a jockey who has dealt with concussions.

US horse racing remains years, if not decades, behind other pro sports — not to mention the sport in other countries — when it comes to concussion evaluation, diagnosis and return to racing protocol for jockeys.

There’s no national concussion programme from state to state or racetrack to racetrack. There is also an ongoing debate on how to implement one and who should pay for it. That leaves jockeys like Smith facing different situations along the Triple Crown trail from the Kentucky Derby to the Preakness in Maryland and Belmont in New York.

The Jockeys’ Guild last month voiced concern about the New York Racing Association’s lack of a concussion protocol, but the problem isn’t limited to one state.

Jockeys not as accomplished or famous as Smith are confronted daily with inconsistent care, especially in the area of brain injuries and head trauma. Not every track has an on-site athletic trainer or physician to diagnose concussions.

“The biggest thing is being able to pull a jockey if there is a suspected concussion, and a lot of racetracks don’t even have that,” said Dr Kelly Ryan, who heads a pioneering concussion protocol program for the Maryland Jockey Club. “So, a jockey could fall, hit his head, can feel dizzy, can feel nauseous, doesn’t even understand that he has a concussion and then will get back on a horse with altered depth perception and reaction times and problems tracking and concentration.”

Head injuries from a fall ended the career of jockey Ramon Dominguez in 2013. According to the British Journal of Sports Medicine, there were 36 reported concussions in US racing from 2012-2016.

But it is unclear how many horse racing concussions have gone unreported. There is currently no official nationwide record-keeping system for jockey injuries and concussions.

A group including Ryan, MedStar, The Jockeys’ Guild, University of Kentucky College of Health Sciences and New York Institute of Technology has come up with concussion guidelines, but they have not been widely implemented because of inequities from place to place.

The Association of Racing Commissioners International added guidelines for tracks to employ a medical professional trained in concussions, give jockeys baseline tests and institute a return-to-ride protocol, but that also must be adopted place to place.

“It’s a long way to go,” Jockeys’ Guild national manager Terry Meyocks said. “We want to be treated like any other professional sports league, amateur or even high school girls’ soccer teams. We just want to be treated the same way.”

The NFL, NBA, NHL and Major League Baseball all have specific concussion policies that are mostly absent in U.S. thoroughbred racing, aside from places like Keeneland in Lexington, Kentucky, Pimlico and Laurel in Maryland and Gulfstream in Florida.

The National Thoroughbred Racing Association (NTRA) is trying to get a handle on the international issue.

“The NTRA Safety & Integrity Alliance regularly consults with racetracks to help establish the most effective protocols feasible in each jurisdiction,” NTRA spokesman Jim Mulvihill said.

While the NTRA is doing the best it can, doctors with experience treating concussions among jockeys consider it a major issue. In a sport where there is significant attention paid to the health and well-being of horses, jockeys and exercise riders are often an afterthought.

“Everyone pays attention to the horses,” Ryan said. “No one pays attention to the jockeys.”