Exertional Headache

By admin On Dec 7, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Exertional Headache

Natalie Voskanian

Basics

There are 2 types of exertional, or exercise-associated, headaches seen in athletes: 1) benign exertional headache (BEH); and 2) weightlifter's headache.
These headache syndromes are not associated with intracranial lesions or systemic disorders, and are distinct from migraines, tension headaches, concussion, and cervicogenic headaches, all of which are also seen in athletes.
Weightlifter's headache, also known as cough headache, is a short-lasting headache that results abruptly from Valsalva maneuvers, such as from weightlifting or resistance training. It has also been called sexual headache because it can result from an orgasm in some individuals.
BEH is believed to be distinct from weightlifter's headache because it lasts longer, has a different population profile, results from more sustained intense exercise, and is usually not associated with Valsalva maneuvers.

Description

BEH occurs typically in young athletes (age range 10–48 yrs old, average age of 24) and lasts several hours on average (1).
BEH is brought on by sustained physical exertion, such as running or doing running drills, rugby, swimming, soccer, swimming, etc.
Weightlifter's headache is usually short-lived and brought on by sudden strains, such as coughing, sneezing, crying, or lifting a heavy object.
Weightlifter's headache lasts only several minutes and is more commonly seen in older individuals (1).
Though historically, the classification of these entities has been vague, most agree that these 2 are distinct entities.

Epidemiology

Exertional headaches occur more often in men (2).

Incidence

BEH affects 1% of the general population (2).
Up to 50% of athletes report regular headaches from sport activity (3).

Risk Factors

Male gender (2)
History of migraine (4)

General Prevention

Avoidance of intense, sustained physical exertion

Etiology

Pathophysiology is largely unknown, but several theories have been postulated:

Systemic BP changes or increases in intra-abdominal/intrathoracic pressures during exercise may lead to increased cerebral arterial pressure or cause dilatation of pain-sensitive venous sinuses (3).
BP changes during exercise in individuals with impaired cerebrovascular autoregulation may lead to inappropriate cerebrovascular dilation (5).
Incompetence of the jugular venous valve may be a potential mechanism (6).

Commonly Associated Conditions

Up to 40% of individuals who experience cough headaches also experience BEH (4).

Diagnosis

History

BEH:
- Is characterized as bilateral, throbbing, pulsatile headache of acute onset
- Begins during or soon after exercise
- Not associated with any head trauma
- Lasts anywhere from 5 min to 24 hr (3)
- Can be prevented by avoidance of exercise or decreased intensity
- Is not associated with vomiting, but may have nausea
Weightlifter's headache:
- Results from a sudden, explosive activity
- Is described as “stabbing”
- Lasts seconds to minutes
Thorough history should aim to:
- Elicit details that may alert to a focal neurologic cause and rule out any history of head trauma
- Identify any red flags suggesting other cause of headache, such as confusion, disorientation, fatigue, blurry vision, seizure activity, numbness or focal weakness, memory or speech impairment, aura, phonophobia, photophobia, blurry or double vision, febrile illness, dizziness, ataxia, or history of head trauma
- Distinguish exertional headache from migraine or tension headache (by identifying if it is unilateral or bilateral, “throbbing,” or “stabbing,” and whether it lasts seconds, minutes, or hours)
- Identify history of migraine disorder in the patient or his/her family
- Identify any past history of bleeding disorders or blood clots

Physical Exam

A complete neurologic examination must be performed.
This should include a funduscopic exam to look for any papilledema, testing of visual fields, and pupillary reflex.
Check bilateral extremity strength, coordination, balance, gait, reflexes, sensation, and cranial nerve function.
Assess mental status. If there are any signs of altered mental status, then it is not BEH.
Look for signs of meningismus or neck stiffness.
Check vital signs, including BP, temperature, pulse, and respiratory rate.
By definition, the neurologic examination will be normal in BEH.
The rest of the exam should be determined by any red flags or key components of the history, which may suggest a systemic cause.

Diagnostic Tests & Interpretation

Imaging

If there are any focal findings or any concern for a structural lesion or a stroke, then neuroimaging, such as CT or MRI, must be done.
Due to increased risk for intracranial pathology with increasing age, many experts recommend doing neuroimaging on any headache that develops above age 40 [Class C].
At younger ages with classic history of BEH and normal exam, imaging is typically not necessary to make the diagnosis.
The decision whether to neuroimage the 1st episode of weightlifter's or cough headache can be a difficult one, due to the fact that this type of headache often develops abruptly and cannot be easily distinguished from SAH on a clinical basis. This decision should be made on a case-by-case basis, depending on risk factors, associated signs and symptoms, and age [Class C].
MRI can better evaluate the posterior fossa than CT scan, but CT more quickly rules out hemorrhage.
An MRA (MR angiogram) can be considered in appropriate circumstances that require assessment of intracranial vasculature.

Diagnostic Procedures/Surgery

Consider lumbar puncture if there is a suspicion for subarachnoid hemorrhage (SAH) and the CT scan is negative.

P.149

Differential Diagnosis

Concussion
Cervicogenic headache
Tension headache
Migraine disorder
Systemic disorder, such as a viral illness
Drug-induced headache
Heat illness
Dehydration
HTN
CNS infection
Intracranial lesion, such as a brain tumor
Subarachnoid hemorrhage (SAH)
Cerebral aneurysm

Treatment

Medication

NSAIDs are typically used to treat BEH as well as to prevent recurrence.
They should be taken 30–60 min prior to the headache-causing physical exertion.
Indomethacin (25 mg PO t.i.d.) and naproxen have been used with success 7[C].
Ergotamine can be used for prophylaxis in cases where NSAIDs are not well tolerated [C], but caution needs to be exercised because of its side effects and drug interaction profile.
Propranolol is another option for prophylactic therapy, although efficacy in BEH has not been proven.

Additional Treatment

General Measures

NSAIDs can cause peptic ulcer disease, stomach irritation, and nausea. In high doses, they can cause renal dysfunction and renal failure. They should be taken with food and used sparingly.
Ergotamine has known complications, including vascular stasis and peripheral vascular constriction, thrombosis, worsening of vascular disease, fibrosis, and increased uterine contractility. It is contraindicated in coronary artery disease, hypertension, liver disease, renal disease, pregnancy, and Raynaud's syndrome. It should be used with caution.

Referral

Consider referral to a neurologist if headache symptoms are atypical or recalcitrant to treatment.

Ongoing Care

Patient Education

Patients should be advised to avoid exercising in the heat and to stay hydrated.
A sudden, severe headache described as “the worst headache” of a patient's life should lead to evaluation in an emergency room.

Prognosis

BEH tends to recur with exercise.
In 1 study that followed 93 patients, 32% of patients with exertional headache sustained complete remission within 5 yrs, and 78% underwent complete remission or significant improvement in 10 yrs (8).
In a small study of patients with sexual headache, 41% had recurrence within 5 yrs (4).

References

1. Pascual J, Iglesias F, Oterino A, et al. Cough, exertional, and sexual headaches: an analysis of 72 benign and symptomatic cases. Neurology. 1996;46:1520–1524.

2. Rasmussen BK, Olesen J. Symptomatic and nonsymptomatic headaches in a general population. Neurology. 1992;42:1225–1231.

3. McCrory P. Headaches and exercise. Sports Med. 2000;30:221–229.

4. Silbert PL, Edis RH, Stewart-Wynne EG, et al. Benign vascular sexual headache and exertional headache: interrelationships and long term prognosis. J Neurol Neurosurg Psychiatry. 1991;54:417–421.

5. Heckmann JG, Hilz MJ, Mück-Weymann M, et al. Benign exertional headache/benign sexual headache: a disorder of myogenic cerebrovascular autoregulation? Headache. 1997;37:597–598.

6. Doepp F, Valdueza JM, Schreiber SJ. Incompetence of internal jugular valve in patients with primary exertional headache: a risk factor? Cephalalgia. 2007.

7. Diamond S. Prolonged benign exertional headache: its clinical characteristics and response to indomethacin. Headache. 1982;22:96–98.

8. Rooke ED. Benign exertional headache. Med Clin North Am. 1968;52:801–808.

Additional Reading

Green MW. A spectrum of exertional headaches. Med Clin North Am. 2001;85:1085–1092.

Headache Classification Committee of the International Headache Society. The international classification of headache disorders. Cephalgia. 2004;24(Suppl 1):9–160.

Turner J. Exercise-related headache. Curr Sports Med Rep. 2003;2:15–17.

Codes

ICD9

339.84 Primary exertional headache

Clinical Pearls

BEH occurs during or soon after intense physical activity and can be prevented by avoiding intense exertion.
It is typically characterized as bilateral, throbbing, and pulsatile. It lasts 5 min to 24 hr, and the average age of onset is 24.
Weightlifter's (or cough) headache is quick in onset, “stabbing,” lasts seconds to minutes, and is associated with the Valsalva maneuver. It more commonly affects older individuals.
Neuroimaging should be considered if there are any signs or symptoms suggestive of intracranial pathology.
Evidence behind diagnosis and management of exertional headaches is limited.