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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. Volume 1 No 2 June 2010 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 5 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? 0 Is s u e 01 c ce r 2 So 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 So 10 Issu 20 e cce r 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 6 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 Volume 1 No 2 June 2010 2010 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. 0 Volume 1 No 2 June 2010 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. 0 Is s u e 01 I ue ss 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. 7 c ce r 2 So 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.