Headache and Exercise

Educational Objectives

The goal of this program is to improve the prevention and treatment of exertional headaches in athletes. After hearing and assimilating this program, the clinician will be better able to:

1. Develop an appropriate strategy for management of primary exercise headaches in athletes.
2. Distinguish various types of headache for appropriate diagnosis and treatment.

Summary

Headache with exercise: ≈33% of adolescents, collegiate athletes, and distance runners, and ≈50% of cyclists report exertional headaches; reports suggest that ≈2% of the general population have discontinued exercise and participation in sports because of exercise-related headache; one study reviewed the association between exercise, sports, and headaches and found ≈67% of reported headaches were benign exertional headaches; International Headache Society — has classified headaches that arise during sports as coincidental to playing sport, induced by playing sport, mechanism-specific to an individual sport, and headaches that occur because of exertion

Common triggers for headache: include sleep deprivation, exercise, travel, emotional stress, dehydration, hormonal fluctuations, food chemicals, and skipping meals; headaches are commonly observed in high school and college athletes because of the presence of these common headache triggers

Mechanism-specific headaches: swim goggle headache or headache related to specific headgear (eg, football helmet); termed as external compression headache, which is caused by pressure exerted by tight face masks, goggles, or helmets resulting in pain in the facial and temporal regions; can be caused by compression of facial nerves from tight facial gear; football helmets have evolved to have a better fit, and some models have an air bladder to prevent compression of facial nerves

Cervicogenic headache: referred pain from structures in the neck; commonly observed in sports athletes; tension-type headache quality; posterior predominance; generally occurs from activities that involve straining; if the patient has full range of neck motion without any tenderness or pain, the cause may not be a cervicogenic headache

Elevation headaches: 1968 Olympic Games — the high altitude of Mexico City caused some participating athletes to have migraine headaches, orbital pain, nausea, and vomiting; some athletes had a prior history of migraine headaches; headache is the most common neurologic symptom at altitudes >7000 ft; treatment options — include acetazolamide (Diamox) and dexamethasone; acetazolamide can be taken preventatively and acutely; for preventative treatment, 125 mg acetazolamide can be taken twice daily, or 4 mg oral dexamethasone can be taken every 6 to 12 hr; for acute treatment, ≥250 mg acetazolamide can be taken twice daily

Primary exercise headache (PEH): commonly referred to as benign exertional headache; can be precipitated by any physical exertion; diffuse, pulsating, and very migraine-like pain in phenotypic presentation; commonly associated with migrainous symptoms, eg, light and sound sensitivity, nausea; generally observed in individuals with an inherent predisposition to migraine; precise etiology is unknown but is believed to be caused by cerebrovascular dilatation, and not by any underlying primary disorder; one study assessing changes in blood pressure (BP) and cardiac output in Olympic weightlifters found that these athletes had BPs of >400/300 mm Hg with maximal lifts, which can lead to headache

Differential diagnosis: sudden onset is a red flag; associated factors include abnormal neuroimaging, headache upon awakening, headache that worsens with Valsalva maneuver, focal deficits, and rapidly increasing headache; absence of these symptoms does not rule out an ominous etiology; clinical suspicion is important

Life-threatening causes of acute headache: include structural etiologies (eg, subdural and epidural hematoma, subarachnoid hemorrhage), infectious processes, and hypertensive encephalopathy

Heat exhaustion: predisposing factors include hot, humid environment, inadequate fluid intake, and muscular body type with body mass index >25; treatment includes cooling, removing excess clothing, elevating the legs, using ice towels or bags, and administering oral fluid; patients with heat exhaustion respond fairly rapidly; patients who do not respond should be taken to the emergency department

Acute-onset headache: any patient with headache and abnormal neurologic examination should undergo emergent noncontrast computed tomography; development of new headaches in patients with HIV indicates urgent neuroimaging tests

Management and treatment of PEH: prognosis is good; it is a diagnosis of exclusion; reports suggest presence of secondary causes has been reported in ≈20% of cases; index of suspicion should be high for secondary causes; the treatment of choice is 25 to 50 mg of indomethacin taken 30 min before physical activity; risk reduction modalities include gradual warm-up before exercise, stretching before and after exercise, cool down after exercise, and adequate hydration before, during, and after exercise

Sex headache: type of exertional headache; ≈1% of Americans have experienced headache related to sex; can be a headache that gradually intensifies during sexual activity or a severe headache that develops explosively at orgasm; can persist from several months to >1 yr; prophylaxis is similar to PEH (25–50 mg of indomethacin taken ≈30 min before sexual activity)

Other types of headaches: hypercapnia headache (diver's headache) — a type of vascular headache that occurs as a result of accumulation of carbon dioxide, seen in scuba divers; other types of headache can be caused by exposure to cold temperature, poorly fitting mouthpiece, or middle ear and sinus barotrauma; airplane headache — a short and intense unilateral headache that usually occurs during descent; predominant in men; often presents with cluster headache-like features and autonomic symptoms; pain is unbearable in >85% of cases, as with cluster headaches; suggested mechanism is barotrauma; prophylactic nonsteroidal anti-inflammatory drugs (NSAIDs) can reduce intensity of the headache

Diagnosing headache in athletes: exclude intracranial causes and drug-induced headache; consider exercise- or sex-related headache syndrome; evaluate for primary headache disorders; exclude associated trauma; consider various types of headache, as they can mimic other health conditions; alcohol, caffeine, analgesics, NSAIDs, and oral contraceptives can cause headaches

Readings

Basnyat B, Gertsch JH, Johnson EW, et al. Efficacy of low-dose acetazolamide (125 mg BID) for the prophylaxis of acute mountain sickness: A prospective, double-blind, randomized, placebo-controlled trial. High Alt Med Biol. 2003; 4(1):45-52. doi:10.1089/152702903321488979; Bogduk N. Cervicogenic headache: Anatomic basis and pathophysiologic mechanisms. Curr Pain Headache Rep. 2001; 5(4):382-386. doi:10.1007/s11916-001-0029-7; Clinch CR. Evaluation of acute headaches in adults. Am Fam Physician. 2001; 63(4):685-692; MacDougall JD, Tuxen D, Sale DG, et al. Arterial blood pressure response to heavy resistance exercise. J Appl Physiol (1985). 1985; 58(3):785-790. doi:10.1152/jappl.1985.58.3.785; Sandoe CH, Kingston W. Exercise headache: A review. Curr Neurol Neurosci Rep. 2018 Apr 19;18(6):28. doi:10.1007/s11910-018-0840-8; Williams SJ, Nukada H. Sport and exercise headache: Part 2. Diagnosis and classification. Br J Sports Med. 1994; 28(2):96-100. doi:10.1136/bjsm.28.2.96.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Seifert was recorded at Headache Update 2021, held July 15-18, 2021, in Lake Buena Vista, FL, and presented by Diamond Headache Clinic Research and Educational Foundation. For information on future CME activities from this presenter, please visit dhc-fdn.org. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

NE130302

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.