Recognizing Exercise-Related Headache

Paul McCrory, MBBS

THE PHYSICIAN AND SPORTSMEDICINE - VOL 25 - NO. 2 - FEBRUARY 97 If your browser does not support tables click here. 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 maneuvers can bring on exertional headache; maximal or submaximal aerobic activity can precipitate effort headache. Trauma to the head and neck can lead to posttraumatic headache. Other headache syndromes in athletes include cervicogenic headache, goggle headache, diver's headache, and altitude 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 or running or walking or hunting or any other unseasonable labor.... (1)" Today as well, physicians need the diagnostic skills to recognize when an athlete's headache is exercise related. Accurately distinguishing 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 IHS criteria. They mostly fall into the miscellaneous category, which limits the utility of this classification system in clinical sports medicine practice. This review concentrates on headache syndromes that are unique to athletes and sport. A recent community study (3) of 1,000 adults that used IHS criteria found that the most common type of headache in the general population is the episodic tension headache, which has a prevalence of 66%. In contrast, benign exertional headache, which is common in athletes, has an overall prevalence of only 1%. Few epidemiologic studies have specifically examined exercise-related headache syndromes. A recent study from New Zealand (4) compiled questionnaire responses about exercise-related headache 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 women than in men. The sports noted to cause all categories of exercise-related headache included running, jogging, weight training, aerobic exercise class, and rugby football. Almost all the posttraumatic 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 the trigemino-cervical pathway, is critical to understanding headache causation. Triggers for activation of this system can include arterial distention and trauma, which may act by suppressing the normal pain control systems in the brain stem. Neurotransmitters that influence intracranial pain pathways include serotonin, peptides, and acetylcholine, which provide the pharmacologic basis for some drug therapy. For example, sumatriptan succinate and methysergide maleate both directly affect serotonin receptors to modulate migraine. Recent advances in molecular biology have suggested a causative role for other 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 the clinical 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, and associated symptoms. Precipitating factors as well as aggravating and relieving factors should be identified. 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 sportand the specific activity being performed at the onset of the headacheis crucial. Knowledge of the patient's treatment history can be helpful, as can information about his or her general health, general medical history, family medical history, and social and occupational history. In addition, the physician should take a thorough drug history, since many commonly used drugs can 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 headaches are brought on by sexual activity, since such headaches are exertion related. Physical exam. In all patients presenting with headache, a full neurologic and general physical examination 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 caf au lait spots [neurofibromatosis]); mental status and speech; 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 cervical spine as a potential source of headache. Laboratory testing. Most headaches are due to benign causes and do not require detailed radiologic investigation. Nevertheless, the physician should be alert for the presence of more serious 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 intracranial pathology is suspected, an urgent workup, which may include neuroimaging studies and laboratory tests, is required.

Table 1. Key Symptoms of Possible Intracranial Pathology 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 (eg, weight loss, fever, malaise) Focal neurologic symptoms or signs Local extracranial symptoms (eg, sinus, ear, or eye disease)

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

Table 2. Clinical Features of Exercise-Related Headache Syndromes Tend Aggravated Normal Normal to Migraine by Neck Physical InvestRecur? History? Movement? Exam? igations? No Yes No No No No Sometimes Yes Yes Yes No No Yes Yes No No

Headache Type

Onset

Pain Duration Quality

Exertional Acute Hours Effort Insidious Hours Posttraumatic Variable Variable Cervicogenic Insidious Days

Throbbing Yes Throbbing Yes Throbbing Yes Constant Yes

Exertional Headache

Benign exertional headache has been recognized as a separate entity for more than 60 years. In 1932, 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 a Valsalva-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 headaches and found that approximately 10% had an organic cause for the pain, usually a skull-base anomaly. Clearly, the major differential diagnosissubarachnoid hemorrhageneeds to be excluded 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 the pain-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 or orgasmic cephalgia (13). Angiographic studies (14) of both benign exertional and benign sex headaches have demonstrated arterial spasm, further implicating the vascular tree as the basis of these conditions. However, despite their vascular nature, no convincing association with migraine 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 patient performs the provoking activity and then slowly resolve without treatment, although some cases may be lifelong. In the recovery period, a graduated symptom-limited weightlifting program is appropriate.

Effort Headache
Effort headaches are the most common type of headache in athletes (16-20) and are associated with a variety of sports. Jokl (16) described running-induced migraine in athletes participating in the 1968 Olympic Games in Mexico City. Other authors (17,18) describe how running prompts similar problems, especially in hot weather. Effort headaches are not necessarily benign: At least one associated case of hemispheric cerebral infarction has been reported (19). Effort headaches are clinically distinguished by mild-to-severe throbbing pain brought on by maximal 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 are more 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 orally three 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 effective in hot weather. As a means of preventing effort headaches, graduated exercise programs have shown limited success (20).

Posttraumatic Headaches
Trauma to the head and neck in sport may lead to headaches. The initiating trauma is not necessarily 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 contraction headache; (2) mixed headache (episodic migraine superimposed on chronic muscle contraction headache); (3) trauma-triggered migraine, which is clinically indistinguishable from migraine and seen in sports such as soccer, which have repetitive heading of the ball (21); (4) traumatic dysautonomic cephalgia due to blows on the anterior neck that trigger autonomic symptoms (22), successfully treated with propranolol hydrochloride; (5) second-impact catastrophic headache, a usually fatal consequence of brain injury thought to be due to diffuse cerebral edema after repeated brain injury (23); and (6) superficial pain at the site of head or skull trauma, which is perhaps the most common type of trauma-induced headache. Treatment of these various posttraumatic headache syndromes usually involves pharmacologic therapy. 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 neural structures of the cervical spine. Athletes are prone to cervical injury, as in collision and contact sports, or cervical dysfunction, both of which may cause a cervicogenic headache. Cervicogenic headaches may also be related to scuba diving, rock climbing, or tennis, in which repeated cervical extension is common. In the strict IHS definition, cervicogenic headache refers to a unilateral headache with symptoms such as blurred vision (2). In clinical practice, it has come to represent a much broader syndrome related to cervical dysfunction rather than objective pathology. However, this expanded definition remains controversial because of the difficulty in objectively demonstrating the relationship between cervical dysfunction and headache (24). Although it is known that the various pain-sensitive structures in the neck can refer pain to the head, how this occurs in the absence of definable cervical pathology remains unclear. Cervicogenic headache shares many of the clinical features of chronic tension headache. At onset, 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 or manipulative therapy to the cervical spine as well as consideration of anti-inflammatory drug therapy.

Other Headache Syndromes

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

Goggle headache , commonly seen in swimmers and scuba divers, is pain in the face and temporal area caused by wearing an excessively tight face mask or swim goggles (25). In divers, "mask squeeze" occurs on descent to depth as increased pressure reduces the air space inside the mask. Better fitting goggles can help alleviate symptoms in swimmers, but not in scuba divers. Diver's headache is a vascular-type headache in scuba divers thought to be due to carbon dioxide accumulation during skip breathing (26). Divers are also prone to headaches from other causes such as cold exposure, muscle or temporomandibular joint pain from gripping the mouthpiece too tightly, middle ear and sinus barotrauma, and cerebral decompression illness. Altitude headache is a type of vascular headache that often accompanies acute mountain sickness in unacclimatized individuals who ascend above 8,000 feet. Treatment involves descending to a lower altitude, although pharmacologic intervention with acetazolamide or sumatriptan succinate is an option.

Reassuring Resolutions
When treating an athlete suffering from headache, the physician should consider the common headache syndromes seen in the general population. However, an awareness of the various sportrelated headache syndromes provides the basis for thorough clinical care. In addition, physicians should recognize that few headaches fail to evoke some anxiety in the sufferer, which can in turn distort clinical symptoms. Reassuring the patient about the clinical course of his or her pain can often help.

References
1. Hippocrates: The Aphorisms of Hippocrates, Coar T (trans). London, Valpy Printers, 1822 2. Headache Classification Committee of the International Headache Society: Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Cephalalgia 1988;8(suppl 7):9-96 3. Rasmussen BK: Epidemiology of headache. Cephalalgia 1995;15(1):45-68 4. Williams SJ, Nukada H: Sport and exercise headache: part 2: diagnosis and classification. Br J Sports Med 1994;28(2):96-100 5. Wolff HG: Headache and Other Head Pain. New York City, Oxford University Press, 1963 6. Olesen J, Thomsen LL, Lassen LH, et al: The nitric oxide hypothesis of migraine and other vascular headaches. Cephalalgia 1995;15(2):94-100 7. Tinel J: La cphale l'effort, syndrome de distension douloureuse des veines intracraniennces. Mdecine 1932;13(Feb):113-118 8. Powell B: Weight lifter's cephalgia. Ann Emerg Med 1982;11(8):449-451 9. Perry WJ: Exertional headache. Phys Sportsmed 1985;13(10):95-99 10. Diamond S, Medina JL: Prolonged benign exertional headache, in Critchley M (ed): Headache: Physiopathological and Clinical Concepts. New York City, Raven Press, 1982, pp 145-149 11. Rooke ED: Benign exertional headache. Med Clin North Am 1968;52(4):801-808 12. MacDougall JD, Tuxen D, Sale DG, et al: Arterial blood pressure response to heavy resistance exercise. J Appl Physiol 1985;58(3):785-790 13. Hazelrigg RL. IV DHE-45 relieves exertional cephalgia. Headache 1986;26(1):52 14. 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 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 Medicine Centre in Melbourne, Australia. He is a fellow of the American College of Sports Medicine, the Australian College of Sports Physicians, and the Australian Sports Medicine Federation. Address correspondence to Paul McCrory, MBBS, Olympic Park Sports Medicine Centre, Swan St, Melbourne, Australia 3004; e-mail to 100401.657@compuserve.com RETURN TO FEBRUARY 1997 TABLE OF CONTENTS HOME | JOURNAL | PERSONAL HEALTH | RESOURCE CENTER | CME | ADVERTISER SERVICES | ABOUT US | SEARCH

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