the physician and sportsmedicine_ recognizing exercise-related headache

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Recognizing Exercise-Related HeadachePaul McCrory, MBBS

THE PHYSICIAN AND SPORTSMEDICINE - VOL 25 - NO. 2 - FEBRUARY 97

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In Brief: Active patients may suffer not only from the common headache syndromes that plague

the general population, but also from headache brought on by exercise. Valsalva-type maneuverscan bring on exertional headache; maximal or submaximal aerobic activity can precipitate effortheadache. Trauma to the head and neck can lead to posttraumatic headache. Other headachesyndromes in athletes include cervicogenic headache, goggle headache, diver's headache, andaltitude headache.

More than 2,000 years ago, Hippocrates noted a connection between headache and exercise:"One should be able to recognize those who have headaches from gymnastic exercises orrunning or walking or hunting or any other unseasonable labor.... (1)" Today as well, physiciansneed the diagnostic skills to recognize when an athlete's headache is exercise related. Accuratelydistinguishing among the many types of exercise-induced headache will help the physician direct

appropriate treatment.

Headache Epidemiology

The International Headache Society (IHS) has proposed an overall classification for headache(2). The main categories include tension headache and migraine, both of which occur in athletes.Headaches that are specifically related to sports, however, are not easily categorized using IHScriteria. They mostly fall into the miscellaneous category, which limits the utility of thisclassification system in clinical sports medicine practice. This review concentrates on headachesyndromes that are unique to athletes and sport.

A recent community study (3) of 1,000 adults that used IHS criteria found that the most commontype of headache in the general population is the episodic tension headache, which has aprevalence of 66%. In contrast, benign exertional headache, which is common in athletes, has anoverall prevalence of only 1%.

Few epidemiologic studies have specifically examined exercise-related headache syndromes. Arecent study from New Zealand (4) compiled questionnaire responses about exercise-relatedheadache from 129 university athletes. Effort-exertion headaches were most common at 60%,followed by posttraumatic headaches (22%), effort migraines (9%), and trauma-induced



migraines (6%). Effort migraine and effort-exertion headaches were more common in womenthan in men. The sports noted to cause all categories of exercise-related headache includedrunning, jogging, weight training, aerobic exercise class, and rugby football. Almost all theposttraumatic headaches occurred in men after they played rugby football.

Anatomy of Head Pain

The most important structures that register pain within the skull are the blood vessels,particularly the proximal part of the cerebral arteries and the large veins and venous sinuses (5).Understanding the interconnections between the intracranial pain pathways, especially thetrigemino-cervical pathway, is critical to understanding headache causation. Triggers foractivation of this system can include arterial distention and trauma, which may act bysuppressing the normal pain control systems in the brain stem.

Neurotransmitters that influence intracranial pain pathways include serotonin, peptides, andacetylcholine, which provide the pharmacologic basis for some drug therapy. For example,sumatriptan succinate and methysergide maleate both directly affect serotonin receptors tomodulate migraine. Recent advances in molecular biology have suggested a causative role forother vasoactive agents in the genesis of headache, which may have important treatment

implications (6).

Clinical Examination

History. When assessing an athlete who has headaches, the most important component of theclinical exam is the history. The physician should determine the patient's age at headache onset,headache frequency and duration, and the time and mode of onset of the individual headache.

The patient should be asked to identify the site of pain and radiation, headache quality, andassociated symptoms. Precipitating factors as well as aggravating and relieving factors should beidentified. Particular emphasis should be placed on recent changes in function and the

development of focal neurologic and systemic symptoms. For athletes and patients suspected of suffering from exercise-related headaches, detailed information regarding the nature and type of the involved sport—and the specific activity being performed at the onset of the headache—iscrucial.

Knowledge of the patient's treatment history can be helpful, as can information about his or hergeneral health, general medical history, family medical history, and social and occupationalhistory.

In addition, the physician should take a thorough drug history, since many commonly used drugscan provoke headaches. Some, such as nonsteroidal anti-inflammatory drugs (NSAIDs), are in

widespread use by athletes. Other common drugs that can cause headaches include analgesics,antibiotics, antihypertensives, corticosteroids, nitrazepam, oral contraceptives,sympathomimetics, theophyline, and vasodilator agents. In addition, use of alcohol, caffeine,nicotine, and street drugs can lead to headache.

The physician should also ask appropriate questions to determine whether the patient's headachesare brought on by sexual activity, since such headaches are exertion related.

Physical exam. In all patients presenting with headache, a full neurologic and general physicalexamination is required. The main examination should include general appearance (including



skin lesions such as rashes [which may indicate viral or bacterial illness], hemangioma[arteriovenous malformations], and café au lait spots [neurofibromatosis]); mental status andspeech; gait, balance, and coordination; cranial nerve and long tract examination; visual fields,acuity, and fundal exam; and skull palpation. Particular attention should be paid to the cervicalspine as a potential source of headache.

Laboratory testing. Most headaches are due to benign causes and do not require detailedradiologic investigation. Nevertheless, the physician should be alert for the presence of moreserious pathology, such as a mass lesion or a viral or other infectious process. Key symptoms of

such intracranial pathology should be sought by specific questioning (table 1). If intracranialpathology is suspected, an urgent workup, which may include neuroimaging studies andlaboratory tests, is required.

Table 1. Key Symptoms of Possible Intracranial Pathology

Sudden onset of severe headacheHeadache increasing over a few daysNew or unaccustomed headache

Persistently 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 (eg, weight loss, fever, malaise)Focal neurologic symptoms or signsLocal extracranial symptoms (eg, sinus, ear, or eye disease)

Headache classification. On the basis of the clinical exam, the physician should be able todifferentiate among vascular, tension, migraine, cervicogenic, and other headache causes. Themajor exercise-related headache syndromes are summarized in table 2 and detailed below.

Table 2. Clinical Features of Exercise-Related Headache Syndromes

HeadacheType Onset Duration

PainQuality

TendtoRecur?

MigraineHistory?

Aggravatedby NeckMovement?

NormalPhysicalExam?

NormalInvest-igations?

Exertional Acute Hours Throbbing Yes No No Yes Yes

Effort Insidious Hours Throbbing Yes Yes No Yes Yes

Posttraumatic Variable Variable Throbbing Yes No Sometimes No No

Cervicogenic Insidious Days Constant Yes No Yes No No

Exertional Headache



Benign exertional headache has been recognized as a separate entity for more than 60 years. In1932, Tinel (7) first described severe but transient headaches following exercise. Since then,these headaches have been associated with exercises such as weightlifting (8) and wrestling (9).

Recent studies (8-10) have delineated a clear-cut exertional headache syndrome: Straining or aValsalva-type maneuver precipitates the acute onset of severe throbbing pain, usually occipital,for a few seconds to a few minutes. The headache then settles to a dull ache lasting 4 to 6 hours.In subsequent weeks to months, the headache recurs with exertion. The patient has no history of migraine and a normal neurologic exam.

In the largest series to date, Rooke (11) followed 103 patients with benign exertional headachesand found that approximately 10% had an organic cause for the pain, usually a skull-baseanomaly. Clearly, the major differential diagnosis—subarachnoid hemorrhage—needs to beexcluded by appropriate investigation.

Exertional headaches are thought to be vascular, but this is unproven. According to one theory,exertional headache occurs because exertion increases cerebral arterial pressure, causing thepain-sensitive venous sinuses at the base of the brain to dilate. Studies of weight lifters (12)demonstrate that, with maximal lifts, systolic blood pressure may reach levels above 400 mm Hg

and diastolic pressures above 300 mm Hg. The throbbing, migrainous nature of these headaches,together with the finding (13) that intravenous dihydroergotamine mesylate can relieve them,supports the supposition that these headaches have a vascular basis.

A related type of vascular headache caused by sexual activity is termed benign sex headache ororgasmic cephalgia (13). Angiographic studies (14) of both benign exertional and benign sexheadaches have demonstrated arterial spasm, further implicating the vascular tree as the basis of these conditions. However, despite their vascular nature, no convincing association withmigraine is demonstrable.

Treatment strategies include NSAIDs such as indomethacin at a dose of 25 mg three times per

day (15). In practice, the headaches tend to recur over weeks to months when the patientperforms the provoking activity and then slowly resolve without treatment, although some casesmay be lifelong. In the recovery period, a graduated symptom-limited weightlifting program isappropriate.

Effort Headache

Effort headaches are the most common type of headache in athletes (16-20) and are associatedwith a variety of sports. Jokl (16) described running-induced migraine in athletes participating inthe 1968 Olympic Games in Mexico City. Other authors (17,18) describe how running promptssimilar problems, especially in hot weather. Effort headaches are not necessarily benign: At leastone associated case of hemispheric cerebral infarction has been reported (19).

Effort headaches are clinically distinguished by mild-to-severe throbbing pain brought on bymaximal or submaximal aerobic exercise. The patient may have prodromal "migrainous"symptoms; the headache will be of short duration, 4 to 6 hours. These vascular headaches aremore frequent in hot weather and tend to recur with exercise. The patient may have a history of migraine; his or her neurologic exam will be normal.

Treatment for effort headaches includes the use of indomethacin (starting dose, 25 mg orallythree times a day with food) or various antimigraine preparations. In the author's experience,



NSAIDs given before exercise can serve a prophylactic function; however, this is less effectivein hot weather. As a means of preventing effort headaches, graduated exercise programs haveshown limited success (20).

Posttraumatic Headaches

Trauma to the head and neck in sport may lead to headaches. The initiating trauma is notnecessarily severe, nor does the degree of injury correlate with headache symptoms.

At least six distinct forms of posttraumatic headache exist (2,5): (1) chronic muscle contractionheadache; (2) mixed headache (episodic migraine superimposed on chronic muscle contractionheadache); (3) trauma-triggered migraine, which is clinically indistinguishable from migraineand seen in sports such as soccer, which have repetitive heading of the ball (21); (4) traumaticdysautonomic cephalgia due to blows on the anterior neck that trigger autonomic symptoms (22),successfully treated with propranolol hydrochloride; (5) second-impact catastrophic headache, ausually fatal consequence of brain injury thought to be due to diffuse cerebral edema afterrepeated brain injury (23); and (6) superficial pain at the site of head or skull trauma, which isperhaps the most common type of trauma-induced headache.

Treatment of these various posttraumatic headache syndromes usually involves pharmacologictherapy. In resistant cases, however, psychological intervention may need to be explored.

Cervicogenic Headache

Cervicogenic headaches are caused by abnormalities of the joints, muscles, fascia, and neuralstructures of the cervical spine. Athletes are prone to cervical injury, as in collision and contactsports, or cervical dysfunction, both of which may cause a cervicogenic headache. Cervicogenicheadaches may also be related to scuba diving, rock climbing, or tennis, in which repeatedcervical extension is common.

In the strict IHS definition, cervicogenic headache refers to a unilateral headache with symptomssuch as blurred vision (2). In clinical practice, it has come to represent a much broader syndromerelated to cervical dysfunction rather than objective pathology. However, this expandeddefinition remains controversial because of the difficulty in objectively demonstrating therelationship between cervical dysfunction and headache (24). Although it is known that thevarious pain-sensitive structures in the neck can refer pain to the head, how this occurs in theabsence of definable cervical pathology remains unclear.

Cervicogenic headache shares many of the clinical features of chronic tension headache. Atonset, the pain is usually occipital and may radiate to the anterior aspect of the skull and face.The headache is usually constant, lasts for days to weeks, and has a definite association with

movement or manipulation of cervical structures. Treatment usually involves physical ormanipulative therapy to the cervical spine as well as consideration of anti-inflammatory drugtherapy.

Other Headache Syndromes

A variety of other headache syndromes have been reported in athletes. These usually have clear-cut precipitating factors that are unique to the sports concerned.



1989;19(5):466-468.15 Diamond S, Medina JL: Prolonged benign exertional headache: clinical characteristics and

response to indomethacin. Adv Neurol 1982;33:145-149.16 Jokl E: Olympic medicine and sports cardiology. Ann Sports Med 1984;1(4):127-169.17 Dalessio DJ: Effort migraine, editorial. Headache 1974;14(1):53.18 Massey EW: Effort headache in runners. Headache 1982;22(3):99-100.19 Seelinger DF, Coin GC, Carlow TJ: Effort headache with cerebral infarction. Headache

1975;15(2):142-145.20 Lambert RW Jr, Burnet DL: Prevention of exercise induced migraine by quantitative

warm-up. Headache 1985;25(6):317-319.21 Matthews WB: Footballer's migraine. Br Med J 1972;2(809):326-327.22 Vijayan N: A new post-traumatic headache syndrome: clinical and therapeutic

observations. Headache 1977;17(1):19-22.23 Saunders RL, Harbaugh RE: The second impact in catastrophic contact-sports head

trauma. JAMA 1984;252(4):538-539.24 Pearce JM: Cervicogenic headache: a personal view. Cephalalgia 1995;15(6):463-469.25 Pestronk A, Pestronk S: Goggle migraine, letter. N Engl J Med 1983;308(4):226-227.26 Bennett PB, Elliott DH (eds): The Physiology and Medicine of Diving, ed 4. Philadelphia,

WB Saunders Co, 1993

Dr McCrory is a neurologist and sports medicine physician at Olympic Park Sports MedicineCentre in Melbourne, Australia. He is a fellow of the American College of Sports Medicine, theAustralian College of Sports Physicians, and the Australian Sports Medicine Federation. Addresscorrespondence to Paul McCrory, MBBS, Olympic Park Sports Medicine Centre, Swan St,Melbourne, Australia 3004; e-mail to [email protected]

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