Headache in Athletes
March 2011
Kevin deWeber, MD, FAAFP
Director, Sports Medicine Fellowship
USUHS
Objectives
• Describe headache types see in those who
exercise
• Outline characteristics of life-threatening
conditions that can cause headaches
• Highlight unique features in treatment of
headaches in athletes
Prevalence of headache in athletes
• 30% of adolescents (13-15) w/ exertional HA
– Cephalalgia 2009
• 36% of college athletes (3% w/ migraines)
– Br J Sports Med 1994; Headache 2002
• 36% of distance runners
– W V Med J 1999
• 50% of Aussie footballers reported HA
Consequences of Exertional HA
• Apprehension --> decreased performance
• Limitation of activity
• Treatment medicines --> performance
Categories of HA in athletes
• Migraines (some are triggered by exertion)
• Traumatic HA
• Primary Exertional Headache (EH)
– No underlying cause known
• Secondary EH (due to underlying
conditions)
– Intracranial hemorrhage, mass lesions, systemic
conditions, medications, etc.
• Cervicogenic EH
Sport and exercise headache: part 2. diagnosis and classification. Br J
Sports Med 1994
Etiology of Exertional Headache
• 10-43% have underlying intracranial
pathology
Neurology referral clinic:
10% of patients with exertional headaches
had an underlying organic cause
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3% Arnold-Chiari malformation
2% Platybasia
1% basilar impression
2% subdural hematoma
2% brain tumor
Rooke ED. Benign exertional headache. Med Clin North Am 1968
Neurology referral clinic, 11 pts:
18% (2) of EH were from
subarachnoid hemorrhage
• 82% were primary (benign)
– J Headache Pain 2008
Neurology referral clinic:
43% of 28 patients with exertional
HA had underlying pathology
• 35% subarachnoid hemorrhage
• 4% metastatic breast cancer
• 4% pansinusitis
Pascual J et al. Cough, exertional, and sexual headaches: an analysis of 72 benign and
symptomatic cases. Neurology 1996
Evaluation of
Exercise Induced Headache
• First objective is to rule out ominous
etiologies
– Subarachnoid hemorrhage, cerebral aneurysm,
Arnold-Chiari malformation, neoplasm, CNS
infection, venous sinus stenosis
Headache “Red Flags”
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Abrupt, severe onset (“thunderclap” onset)
Loss of consciousness/confusion
Stiff neck, meningeal signs
Change in previously existing HA character
Onset of HA after age 50
HA associated with head/neck trauma
Neurologic deficits or papilledema
Nocturnal onset/awakening
Increasingly severe over several days
Headache “Red Flags”
(cont.)
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HA increases in severity with lying down
HA is constant and progressive
HA occurs exclusively in one region
History of cancer or HIV infection
Seizures
Evaluation of the acute, severe headache
Evaluation of worrisome HA
• Labs
– CBC, Chemistry, BUN/Cr, ESR
• Neuroimaging
– CT w/ contrast or MRI
– Consider MRA of intracranial vasculature
• Consider LP for CSF analysis
– Blood, cells, pressure, culture
Clinical Case
A 52 yo healthy female was at her
usual jazzercize class 2 d/a when
she notes onset of acute HA on
left side of her head. It has
pounding quality, is moderately
severe, and associated with partial
visual loss on right visual field.
HA has lessened to 1/10, but
visual loss persists.
ROS: No other sxs
PMH: h/o migraines
Exam: visual acuity 20/20 but
with patchy visual field deficit.
Neuro exam is o/w normal.
Intracranial Hemorrhage
• Most common atraumatic cause in athletic
population is Subarachnoid Hemorrhage
– Majority due to aneurysm
• Precipitating factor in athletics is elevated
blood pressure
• Classic presentation = explosive HA, neck
stiffness, photophobia, collapse
• “Worst headache I’ve ever had”
• “thunderclap headache”
Intracranial Hemorrhage:
Management
• Take athlete immediately to ED
• CT scan, LP if negative
• Neurosurgical referral
Mass lesion headache
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Usually starts mild and worsens slowly
Occasionally associated with neuro deficit
Risk factor: HA that begins after age 50
Risk factor: HA located always in one spot
May have symptoms of increase ICP
Mass lesion headache:
usually related to
increased intracranial pressure
• Pain during cough, sneeze, strain, bending
forward, and/or sexual orgasm
• Rapid onset; usually bilateral but
distribution variable
• Severe pain for a few minutes that fades to
dull ache lasting up to 24 hours
• Up to 25% of patients with Valsalvainduced HA have intracranial lesion
– CT or MRI indicated
Exercise-induced headache from
systemic conditions
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Hypoglycemia
Hypertension
Dehydration
Sinus disease
Hyperthermia
Pheochromocytoma
Cardiac ischemia (“cardiac cephalgia”)
Medication-related
exercise-induced headache
• Thermogenic (weight loss) aids
• Anabolic steroids
• Stimulants
Exercise Induced Migraine
• Short periods of vigorous activity
– Cycling, sprinting, swimming, weightlifting
• Unilateral, severe, throbbing / pounding,
preceded by aura
• +/- nausea and vomiting
• +/- phono-/photo-phobia
• Often incapacitating
Trauma Induced Migraine
• Terrell Davis in Superbowl 32 in 1998
• Migraine from kick to the head
Migraine headache:
Abortive treatment
• Acetaminophen/NSAID’s work in a few
• Specific abortive meds needed in most
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Triptans (5-HT1 agonists)
Ergotamine agents
Antiemetics
Butorphanol nasal spray
Intranasal lidocaine 4% drops
Migraine headache:
Abortive treatment (cont.)
• Triptans are tx of choice in athletes if
unresponsive to analgesics
– Less sedation than with most other meds
– Rapid onset
• Multiple options available
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Sumatriptan (SC, oral, nasal spray)
Rizatriptan (oral)
Zolmitriptan (oral)
Naratriptan (oral)
Migraine headache:
Abortive treatment (cont.)
• Side effects of Triptans
– Somnolence, atypical pain, dizziness
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Rest in quiet, dark room is helpful
Repeat prn as indicated
Return to play is possible if HA aborted
Contra-indications
– CAD, uncontrolled HTN, Prinzmetal’s angina
Migraine headache:
Abortive treatment (cont.)
• Other meds effective but more side-effects
– Dihydroergotamine (nasal, SC, IV, IM)
• Nausea, vomiting, chest pain, tachycardia
– Prochlorperazine (IM, IV)
• Sedation, blurred vision, dizziness
– Combination meds (Fiorinal, Midrin)
• Sedation
– Opiates (butorphanol nasal)
• Sedation; overuse risk
Migraine headache:
Prophylaxis
• Indications
– More than 1-2 HA’s/month
– HA’s not responsive to abortive treatment
– HA’s so severe that they are disabling
• Takes several weeks to see benefit
• Start at low dose (to avoid side effects) and
titrate up
• 6 month trial before trying another agent
Migraine headache:
Prophylactic meds with relatively
low side effect profiles for athletes
• Naproxen 500 mg QD
– Excellent choice if effective
• Vitamin B2 (riboflavin) 200 mg BID
– Some decent evidence of effectiveness
• Verapamil 240 mg QD
– Not very effective, but well-tolerated if it works
• Fluoxetine 20-40 mg QD
– Not very effective, but well-tolerated if it works
Migraine headache:
Prophylactic meds with higher side
effect profiles but quite effective
• Nortriptyline - titrate up from 10 QHS
– Watch for sedation, blurred vision
• Beta-blockers - effective, BUT:
– Banned by in many sports
– Exercise intolerance common
• Valproex, topiramate,
• Gabapentin, methysergide
– Effective, but use only if in a pinch due to side
Primary (Benign) Exertional
Headache
• Should be a
diagnosis
of
exclusion
Primary exertional headache
• Precipitated by prolonged exercise
– Develops during or after exercise
– Running, swimming, cycling, skiing most often
implicated
– Intensity builds as exercise continues
– Etiology: ? Cerebrovascular dilation
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Tends to be bilateral and pulsating
Often with migrainous symptoms
Last 5 min to 2 days
Not due to underlying disorder
Primary exertional headache
• Comorbidity with migraine common
– 40-50%
Primary exertional headache:
Workup
• Perform CT or MR imaging to r/o
secondary causes (10-43%)
– SAH most common
Primary exertional headache:
Treatment and prevention
• Acute Treatment
– NSAID
– Triptans if migrainous
• Consider prophylactic meds if recurrent
– Beta-blockers
– Indomethacin 50-150 mg/day
Cervicogenic EH
“Weight Lifter’s Headache”
• A variant of benign exertional HA
• Referred pain from structures in neck
• Begins abruptly during or immediately
following activities involving straining
• Tension HA-like quality
• Usually posterior, radiates anteriorly
• Lasts seconds to minutes
– May be followed by diffuse, dull HA for hours
Cervicogenic EH:
Treatment
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Ice
Analgesics
Massage
Physical therapy modalities
Manipulation
Altitude Headache
• Occurs at altitude >2500 meters
in those not acclimatized
• Component of Acute Mountain Sickness
– Severe -- High Altitude Cerebral Edema
• Throbbing, generalized
Altitude Headache:
Treatment
• Prevention:
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Best: acclimatization, gradual climb
Acetazolamide (prevents AMS)
ASA 320 mg daily x3d works (Headache 2001)
Sumatriptan works (Ann Neurol 2007)
• Treatment
– Descent
– Time for acclimatization
– NSAIDs
Diver’s headache
• Multi-factorial
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Hypercapnia
Cold stimuli
Decompression sickness (bad)
Excessive gripping of mouthpiece
Sinus barotrauma
Tight goggles, helmet
Mask squeeze
Getting hit on head by pipe
Post-traumatic Headache types
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Intracranial bleed
Chronic muscle contraction
Tension-vascular
Migraine (“footballer’s”)
Dysautonomic cephalgia
Post-concussion syndrome HA
Local nerve entrapment
Post-traumatic Headache:
Chronic muscle contraction
• May be component of Postconcussion
Syndrome
• Treat as tension HA
Post-traumatic Headache:
“Footballer’s migraine”
• Caused by heading ball
• Seen in boxers and wrestlers after head
impact
• Symptoms same as a migraine HA
• Abortive tx same as regular migraine
• Prophylactic meds not very successful
Post-traumatic Headache:
Dysautonomic Cephalgia
• Cause: damage to cervical sympathetic
fibers in the neck at the time of head injury
• Occurs up to months after injury
• Severe, unilateral, fronto-temporal
• Ipsilateral pupil dilation, sweating, vision
changes
• Treatment: beta-blockers
Posttraumatic Headache:
Post-Concussion Syndrome
• HA as part of symptom complex:
– Dizziness, tinnitus, diplopia, blurred vision,
irritability, anxiety, depression, fatigue, sleep
disturbance, poor appetite, poor memory,
impaired concentration, slowed reactions
• HA is probably tension type
• Treat as with chronic tension HA
• Goes away with time (up to months)
Exacerbation of pre-existing
headache syndromes
• Migraines, tension HA, mixed, cluster
• Treat as usual
Review
• Exertional HA has a significant incidence of
underlying pathology
– 10-43% with pathology
– Thorough w/u at onset
• First objective is to rule out ominous etiologies
– Subarachnoid hemorrhage, cerebral aneurysm, ArnoldChiari malformation, neoplasm, CNS infection
• Remember HA “red flags”
Headache “Red Flags”
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Abrupt, severe onset (“thunderclap” onset)
Loss of consciousness/confusion
Stiff neck, meningeal signs
Change in previously existing HA character
Onset of HA after age 50
HA associated with head/neck trauma
Neurologic deficits or papilledema
Nocturnal onset/awakening
Increasingly severe over several days
Headache “Red Flags”
(cont.)
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HA increases in severity with lying down
HA is constant and progressive
HA occurs exclusively in one region
History of cancer or HIV infection
Seizures
QUESTIONS?