Download Exercise-associated Headaches

Exercise-associated Headaches
Dr Jon Patricios
Sports Physician
Rosebank
The epidemiology of exerciseassociated headache is unclear
but they do appear to be common
with up to 1/3 of university
students having suffered from
such headaches and the 20-40
year age group appearing to be
most affected.
Athletes, as with any person, may
suffer from all types of headache
but it appears from the above
data that specific interest lies in
the exercise and effort related
conditions as well as traumarelated pathologies.
Causes of headache
Understanding the factors that
may influence the onset, severity
and nature of the headache
may allow for more effective
intervention.
The most important structures
that register pain within the skull
are the blood vessels, particularly
the proximal part of the cerebral
arteries, as well as the large veins
and venous sinuses.
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Neurotransmitters integral to
this pathway include serotonin,
peptides and acetylcholine which
is why specific medications which
directly affect the serotonin
receptor such as sumatriptan and
methysergide may by effective.
There is no simple mechanism
that explains a migraine attack
but two theories have been
proposed: 1) neurovascular
inflammation and 2) serotonin
dysregulation. A pain generator
or trigger (this may be exercise)
causes the trigeminal nerve
to release inflammatory
chemicals into the brain causing
migraine symptoms. This may
be associated with a triggeractivated drop in serotonin levels.
Clinical evaluation
In assessing an athlete presenting
with headache, classification of
the condition and determining
the possible cause can usually
be determined from the history
and clinical examination. The
following historical factors may
provide some guidance:
• General medical history
• Previous medical history
• Allergies (foods, medication
and environmental – athletes
often train outdoors and
may develop sinus-related
symptoms)
• Family medical history –
general and headache/
migraine-related
• Medication use (see table II)
• Alcohol and recreational drug
use
• Social and occupational
history
Headache-specific questioning:
• Age of onset of the headaches
• Frequency and duration
• Time of onset of headache
• Mode of onset
• Site of pain and radiation
• Headache quality
• Associated symptoms
• Precipitating factors
• Aggravating and relieving
factors
• Previous treatments
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Table I.
Headache prevalence in athletes
(adapted from Williams and Nukada)
Headache type
Effort migraine
Trauma-induced migraine
Effort/exertion headache
Post-traumatic headache
Miscellaneous
Headache
prevalence (%)
9
6
60
22
3
Table II. Commonly used drugs that may
cause headache in athletes
Alcohol
Anabolic steroids
Analgesics
Antibiotics
Antihypertensives
Caffeine
Corticosteroids
Dipyridamole
NSAIDs
Nicotine
Nitrazepam
Oral contraceptives
Sympathomimetics
Theophylline
Vasodilator agents
• NSAIDs = nonsteroidal anti-inflammatory drugs
• Drugs in bold are those most often used by athletes for
treatment, ergogenic or recreational purposes
Importantly:
• Exclude more common
organic causes of headache
(headache in an exercising
person does not necessarily
mean it is exercise-induced):
Are there symptoms and signs
of a viral or other infection?
• Exclude headaches related
to commonly used drugs
(headache-provoking drugs
include non-steroidal
anti-inflammatory drugs
commonly used by
sportspersons) and alcohol
abuse (sportsmen are not
immune to this!)
• Consider vascular, tension
and, particularly in contact
and collision sports,
cervicogenic causes.
• Is the headache associated
with exercise (including
sexual intercourse)? If so, was
trauma involved? If not, are
the headaches recurrent and
consistently associated with
exercise and at what intensity
and duration?
Are there any “Red Flags” that
suggest a possible mass lesion
or infective process that requires
urgent investigation?
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eadache associated
with exercise remains
one of the more
common ailments an
athlete may face and yet its exact
pathophysiology remains unclear.
Indeed even the International
Headache Society (IHS) does not
adequately define or classify the
concept. Certain types of
headache such as migraine are
more common in younger
populations anyway and therefore
not infrequently associated with
exercising individuals. This is not
a new phenomenon. Hippocrates
cautioned his students to "…be
able to recognise those who have
headache from gymnastic
exercises, or running, or walking,
or any seasonal labour.” Sports
physicians need to be aware of
the different types of headache
with which athletes may present
and develop a systematic
approach to diagnosis and
management.
A thorough general and
neurological examination is
mandatory. Important aspects
include:
• General appearance – skin
lesions, rashes
• Vital signs – blood pressure,
pulse and temperature
• Skull & neck palpation and
auscultation for bruits
• Detailed cervical assessment
• Mental status and speech
• Visual fields, acuity and
examination of fundi
• Cranial nerve and long tract
evaluation
• Gait, balance and coordination assessment
The pre-eminent Australian
sports neurologist Paul McCrory
has grouped and described
headaches in athletes according
to the IHS classification noting
that the system does allow for
overlap and some blurring of
terminology especially regarding
“exertion” and “effort”.
Headaches seen in athletes
1. Headaches not specifically
associated with exercise
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1.1 Migraine (IHS 1.1 – 1.7)
Migraine is an episodic brain
disorder that is usually
accompanied by nausea and/
or photophobia that is set off
by a specific trigger and may be
preceded by focal neurological
symptoms. Specifically the IhS
criteria include:
1. at least 5 attacks lasting 4-72
hours;
2. two of the following
characteristics: unilateral,
throbbing, moderate to
severe intensity, aggravated
by routine activity and
3. one of these associated
symptoms: nausea, vomiting,
phonphobia or photophobia.
One third of patients have an
aura or neurologic change (most
often visual, before or during the
migraine. Migraine in children
is more likely to be bilateral and
shorter in duration.
There is often an inherited
predisposition but also a
lower threshold to triggers of
headache such as trauma and
exercise stress. No treatment
template exists and management
strategies should be indvidualised
particularly targeting identified
triggers. Pain management may
be via a variety of analgesics.
Importantly, in competitive
sport, certain commonly used
medications are on the World
Anti Doping Authority (WADA)
banned substances list and need
to be avoided. These include
beta-blockers, opiods and
dextroproxyphene.
1.2 Tension-type headaches
(IHS 2.1 – 2.3)
These headaches characterised
by a tight or pressing sensation
may initially be provoked by a
stressful situation (including prematch apprehension) but may
become chronic without obvious
precipitating psychological
factors. They are often milder in
severity and longer in duration
than migraines and treated by
physiotherapy and psychological
intervention as well as
pharmacological therapy.
1.3 Cervicogenic headaches
(IHS 11.2)
These headaches arise from acute
or chronic changes to a number
of cervical structures including
ligaments, discs, nerve roots,
synovial joints, ligaments and
muscles. Often these structures
may be injured in the same
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mechanism that accounted for a
concussion and be responsible
for lingering pain following such
an injury. The pain is usually
occipital in origin, radiating
to towards the anterior scalp
and is exacerbated by cervical
movement and manipulation.
Treatment is with physiotherapy
and NSAIDs.
2. Headaches more
specifically associated with
exercise.
2.1 Benign exertional
headache (IHS 4.5)
This condition is provoked by
valsalva and straining type
manoeuvers such as those
associated with weightlifting
and competitive swimming. A
headache of similar aetiology
labeled orgasmic cephalgia or
benign sex headache (IHS 4.6)
has been described. They should
be differentiated from exerciseassociated headaches and
exertional migraines that follow
exercise but are not provoked
by straining. The cause may be
dilatation of the venous sinuses
at the base of the brain as a result
of increased cerebral artery
pressure associated with exertion.
The pain is usually bilateral and
throbbing, lasting 5 minutes
to 24 hours. Treatment is with
NSAIDs such as indomethacin
25mg three times a day whilst
ergotamine and propranolol
pre-exercise have also been
described. A gradual symptomguided return to weightlifting and
valsalva-provoking activities is
recommended.
2.2 Effort Headache
Not specifically defined in the IHS
category, these headaches are
nevertheless a definite clinical
entity representing headaches
triggered by endurance exercise
but not necessarily associated
with power or straining activities.
They have been described
as being the most common
headaches presenting in athletes
and may be more common in
hot weather and high altitude.
The headaches tend to last for
4-6 hours and be throbbing in
nature. Pre-exercise NSAIDs may
be effective in treatment whilst
graduated exercise exposure
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These include:
• Sudden onset of severe
headache
• Headache increasing over a
few days
• New or unaccustomed
headache
• Persistently unilateral
headaches
• Chronic headache with
localised pain
• Stiff neck or other signs of
meningism
• Focal neurological symptoms
or signs
• Atypical headache/change in
the usual pattern of headache
• Headaches that wake the
patient during the night or
early morning
• Local extra-cranial symptoms
(e.g. sinus, ear or eye disease)
• Systemic symptoms (e.g.
weight loss, fever and malaise)
2.3 Acute Post-traumatic
Headache
This category represents a
spectrum of often overlapping
syndromes initiated by varying
degrees of head trauma.
2.3.1 Post-traumatic migraine
may be triggered by minor
trauma such as heading a
football (“footballer’s migraine”)
but present with disturbing
symptoms that may include
migrainous cortical blindness.
However symptoms tend to
resolve in 1-2 hours. Symptoms
lasting greater than 24 hours
are unusual and the differential
diagnosis of concussion
should then be entertained,
the appropriate serial clinical
evaluations instituted and
exercise avoided until a week
after full symptom resolution
and the completion of a graded
exercise programme.
2.3.2 Extracranial vascular
headache is a periodic headache
at the site of previous head or
scalp trauma. Treatment is as for
migraine.
2.3.3 Dysautonomic cephalgia
is an extremely rare condition
resulting from trauma to the
anterior neck injuring the
sympathetic trunk and local
ganglia. Treatment is usually with
propranolol (WADA prohibited).
2.3.4 Overlap syndromes
characterised by features of both
cervicogenic and tension-type
headaches and may include
analgesic rebound phenomena.
These are usually treated with
physiotherapy.
2.5 High Altitude Headache is
a well-described component of
altitude sickness manifesting
with 24 hours of ascent to
greater than 3000m. Gradual
descent s indicated whilst
pharmacological interventions
include acetazolamide, ibuprofen
and sumatriptan.
2.6 Hypercapnoea headache
(IHS 10.2)
Divers’ headache is a vascular
type of headache that is thought
to be due to carbon dioxide
accumulation during ‘skip’
breathing. The arterial pCO2
level is usually increased above
50mm Hg in the absence of
hypoxia. Divers are also prone
to headaches from other causes
such as cold exposure, muscular
or temporo-mandibular joint pain
from gripping the mouthpiece too
tightly, cervicogenic headaches
from incorrect buoyancy
technique, middle ear and
sinus barotrauma and cerebral
decompression illness.
In patients with exerciseassociated headaches, general
and neurological examinations
are usually normal. Whilst
investigating further the offending
exercise should be stopped.
MRI or CT imaging is indicated
to exclude intra-cranial lesions
such as tumours, arterio-venous
malformations, aneurysms and
Arnold-Chiari malformation, and
a lumbar puncture to rule out
intracranial blood.
Management strategy
Interventions should be initially
non-pharmacological including
specific exercise avoidance or
adjustment of exercise intensity.
Supplements that have been
described as being beneficial
include magnesium (citrate or
chelated) 200mg twice daily, and
riboflavin 200mg bd. The use of
these should be sustained for at
least 3 months. Oxygen should be
used at high altitudes, and tight
face masks or goggles released.
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The standard pharmacological
treatment for infrequent
headaches that are predictably
associated with exercise is
50-100mg of indomethacin 1-2
hours before exercise. Diclofenac
potassium is also effective. The
anti-inflammatory and nitric
oxide antagonist effects may help
reduce intra-cranial pressure.
More frequent headaches may be
treated with lower daily doses.
In these cases renal function
should be monitored. The use of
beta-blockers is contra-indicated
both because of its classification
as a prohibited substance
in competitive sport and its
bradycardic effect.
Other forms of treatment
are aimed at decreasing the
irritability of the pain generator
and include calcium channel
blockers such as flunarazine
and verapamil. Tricyclic
anti-depressants such as
amitryptalline and anti-epileptic
agents including valproic
acid may help to address the
serotonin abnormalities seen in
migraineurs.
Migraine abortive medications
that have a vasoconstrictive effect
may also be appropriate and best
administered as a wafer or nasal
spray. These include sumatriptan,
zolmitriptan and rizatriptan.
Conclusion
As with most conditions in
clinical medicine, headaches
associated with exercise do not
come “labeled” and can have
features suggestive of different
causes. A careful history,
examination and prudent use of
investigations should determine
whether exercise is in fact the
cause. A systematic approach
and classification of the type
of headache will allow for both
non-pharmacological and drug
therapy that should facilitate
a return to sport, bearing
in mind that some standard
headache therapies may either
be prohibited in competitive
sport or have side effects that are
exacerbated by exercise.
References on request.
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2.4 External Compression
Headache (“Swim Goggle
Headache” or “Mask Squeeze”)
results from wearing tight
goggles, face masks, strapping or
headgear and probably results
from continuous pressure
stimulation of cutaneous nerves.
This amounts to a benign
discomfort that may either be
tolerated for the duration of
the exercise or dealt with by
addressing the cause.
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has been described with varying
success. Such headaches in
athletes over 50 should be a
prompt for cardiac evaluation
as “cardiac cephalgia” may be
a manifestation of myocardial
ischaemia.