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Headaches with Exercise

Athletes, like the rest of the general population suffer from headaches. Theseinclude the common ones including migraine, muscle contraction, stress, TMJdysfunction, drug induced etc. There are however two types of headache specificto exercise, and these will be discussed in this article.

Information gathered for this article came from a Med line search to 1968. Using"effort exertional headache" as key words, thirty articles were found and 8 werereviewed.

A web search produced an excellent review article, "Recognizing Exercise-Related Headache", Paul McCrory, MBBS THE PHYSICIAN ANDSPORTSMEDICINE - VOL 25 - NO. 2 - FEBRUARY 97

Headache associated with exercise can be separated into Effort and Exertionalheadache.

Exertional Headaches

Exertional headaches1 have be recognized for many years and are usuallyassociated with such activities as weight lifting and wrestling (Level 4 evidence).Usually the patient will describe a straining or Valsalva type exertion that leadsto the sudden onset of a severe throbbing pain in the occipital region. Thissevere pain lasts for a few minutes and is replaced by a dull aching pain that maylast for hours. The pain recurs when the patient exerts him/herself again. Whenyou see the patient there are no neurologic findings and if the headache is gone

the patient usually appears well.

It is felt that the etiology of these headaches is vascular, possibly due toexertional increases cerebral arterial pressure, causing the pain-sensitive venous

sinuses at the base of the brain to dilate. MacDougall2 demonstrated that duringmaximal lifts, the systolic blood pressure can reach levels above 400 mm Hg andthe diastolic pressure can top 300 mm,Hg. (Level 3 evidence) Angiographic

studies3 of both benign exertional and benign sex headaches have demonstratedarterial spasm, further implicating the vascular tree as the basis of theseconditions (Level 3 evidence). Despite the fact the headaches are throbbing innature and that intravenous dihydroergotamine mesylate can relieve them, there

is no demonstrated association with migraine.

An important condition in the differential diagnosis of this sort of headache isSubarachnoid Headache. Because the symptoms may mimic those of a warningheadache from an aneurismal leak, it is prudent to do the appropriate

investigations to rule out this condition.4 (Level 4 evidence). This is a conditionthat you do not want to miss, and must be considered with any "first or worstheadache".

These headaches can be managed acutely with NSAIDs. The studies looking at

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treatment usually used Indomethacin5, but they are older studies, so presumablythe newer NSAIDs would work as well without the side effects of indomethacin.

Exertional headaches of this type tend to recur over weeks to months when theactivity is repeated. Gradually they subside, although they have persisted foryears. Once gone the activity can be resumed using the maxim "start low and goslow".

Effort Headache

These are the most commonly encountered headaches associated with exercise.

A study from New Zealand6 involving 129 university athletes demonstrated thateffort headaches were the most commonly recorded at 60%, followed by posttraumatic headaches (22%), effort migraines (9%), and trauma-inducedmigraines (6%) (Level 3 evidence). These headaches are usually described as athrobbing, mild to severe pain, occurring after maximal or sub maximal aerobicexercise. These headaches may last up to several hours and are more common inwomen. They may have a migrainous prodrome, and are more frequent in hotweather.

Effort headache can be treated with NSAIDs. McCrory suggests indomethacin,

but once again most NSAIDs should work1 (Level 4 evidence). Anti-migrainousmedications have also been used with success. NSAIDs given before exercisemay serve a prophylactic function. Obviously anti-migraine therapy withvasoconstricting effects is not recommended prior to aerobic exercise.

When a patient presents with with exercise induced headache ( as with any othertype of headache) it is important to watch for the "red flags". These include:

Sudden onset of severe headache

Headache increasing over a few daysNew or unaccustomed headachePersistently unilateral headachesAtypical headache or a change in the usual pattern of headacheHeadaches that wake the patient during the night or early morningChronic headache with localized painStiff neck or other signs of meningismSystemic symptoms (e.g. weight loss, fever, malaise)Focal neurologic symptoms or signsLocal extracranial symptoms (e.g. sinus, ear, or eye disease)

Should any of these flags occur appropriate and prompt investigation iswarranted.

- John Hickey

Thanks to Dr. Allan Purdy, Professor and Head. Division of Neurology,

Dalhousie University in Halifax, Nova Scotia for reviewing the draft copy of thisarticle.

References:

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.1 Recognizing Exercise-Related Headache, Paul McCrory, MBBS THEPHYSICIAN AND SPORTSMEDICINE - VOL 25 - NO. 2 -FEBRUARY 97

.2 MacDougall JD, Tuxen D, Sale DG, et al: Arterial blood pressure responseto heavy resistance exercise. J Appl Physiol 1985;58(3):785-790

.3 Silbert PL, Hankey GJ, Prentice DA, et al: Angiographically demonstrated

arterial spasm in a case of benign sexual headache and benign exertionalheadache. Aust N Z J Med 1989;19(5):466-468

.4 The New England Journal of Medicine -- January 6, 2000 -- Vol. 342, No.1 Primary Care: Avoiding Pitfalls in the Diagnosis of SubarachnoidHemorrhage Jonathan A. Edlow, Louis R. Caplan.

.5 Diamond S, Medina JL: Prolonged benign exertional headache: clinicalcharacteristics and response to indomethacin. Adv Neurol 1982;33:145-149

.6 Williams SJ, Nukada H: Sport and exercise headache: part 2: diagnosisand classification. Br J Sports Med 1994;28(2):96-100

You can search for abstracts of the above references by following this link:PubMed

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