Headaches with Exercise

Athletes, like the rest of the general population suffer from headaches. These include the common ones including migraine, muscle contraction, stress, TMJ dysfunction, drug induced etc. There are however two types of headache specific to 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 were reviewed.

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

Headache associated with exercise can be separated into Effort and Exertional headache.

Exertional Headaches

Exertional headaches1 have be recognized for many years and are usually associated with such activities as weight lifting and wrestling (Level 4 evidence). Usually the patient will describe a straining or Valsalva type exertion that leads to the sudden onset of a severe throbbing pain in the occipital region. This severe pain lasts for a few minutes and is replaced by a dull aching pain that may last for hours. The pain recurs when the patient exerts him/herself again. When you 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 to exertional increases cerebral arterial pressure, causing the pain-sensitive venous sinuses at the base of the brain to dilate. MacDougall2 demonstrated that during maximal lifts, the systolic blood pressure can reach levels above 400 mm Hg and the diastolic pressure can top 300 mm,Hg. (Level 3 evidence) Angiographic studies3 of both benign exertional and benign sex headaches have demonstrated arterial spasm, further implicating the vascular tree as the basis of these conditions (Level 3 evidence). Despite the fact the headaches are throbbing in nature 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 is Subarachnoid Headache. Because the symptoms may mimic those of a warning headache from an aneurismal leak, it is prudent to do the appropriate investigations to rule out this condition.4 (Level 4 evidence). This is a condition that you do not want to miss, and must be considered with any "first or worst headache".

These headaches can be managed acutely with NSAIDs. The studies looking at treatment usually used Indomethacin5, but they are older studies, so presumably the 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 the activity is repeated. Gradually they subside, although they have persisted for years. Once gone the activity can be resumed using the maxim "start low and go slow".

Effort Headache

These are the most commonly encountered headaches associated with exercise. A study from New Zealand6 involving 129 university athletes demonstrated that effort headaches were the most commonly recorded at 60%, followed by post traumatic headaches (22%), effort migraines (9%), and trauma-induced migraines (6%) (Level 3 evidence). These headaches are usually described as a throbbing, mild to severe pain, occurring after maximal or sub maximal aerobic exercise. These headaches may last up to several hours and are more common in women. They may have a migrainous prodrome, and are more frequent in hot weather.

Effort headache can be treated with NSAIDs. McCrory suggests indomethacin, but once again most NSAIDs should work1 (Level 4 evidence). Anti-migrainous medications have also been used with success. NSAIDs given before exercise may serve a prophylactic function. Obviously anti-migraine therapy with vasoconstricting effects is not recommended prior to aerobic exercise.

When a patient presents with with exercise induced headache ( as with any other type of headache) it is important to watch for the "red flags". These include:
  • Sudden onset of severe headache
  • Headache increasing over a few days
  • New or unaccustomed headache
  • Persistently unilateral headaches
  • Atypical headache or a change in the usual pattern of headache
  • Headaches that wake the patient during the night or early morning
  • Chronic headache with localized pain
  • Stiff neck or other signs of meningism
  • Systemic symptoms (e.g. weight loss, fever, malaise)
  • Focal neurologic symptoms or signs
  • Local extracranial symptoms (e.g. sinus, ear, or eye disease)

Should any of these flags occur appropriate and prompt investigation is warranted.

- 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 this article.

References:
  1. Recognizing Exercise-Related Headache, Paul McCrory, MBBS THE PHYSICIAN AND SPORTSMEDICINE - VOL 25 - NO. 2 - FEBRUARY 97
     
  2. MacDougall JD, Tuxen D, Sale DG, et al: Arterial blood pressure response to 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 exertional headache. 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 Subarachnoid Hemorrhage Jonathan A. Edlow, Louis R. Caplan.
     
  5. Diamond S, Medina JL: Prolonged benign exertional headache: clinical characteristics and response to indomethacin. Adv Neurol 1982;33:145-149
     
  6. Williams SJ, Nukada H: Sport and exercise headache: part 2: diagnosis and 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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