Exercise headacheExercise headache is provoked by physical activity, which could be anything from running, rowing or cycling, climbing stairs or even sexual activity. The usual story is that on starting exertion, a headache,usually of a throbbing or pulsating nature, will build up over a few minutes (or even shorter in some). The pain is usually on both sides of the head, and can last from 5 minutes to almost 2 days. In some people the pain evolves into a pain very similar to a migraine - throbbing quality of pain with intolerance of light, noise, smell or movement - in which case the term exercise induced migraine is used. In people without a serious cause the headache is usually mild at onset and builds fairly slowly. In the more serious cases, the onset can be acute, severe and maximal at onset, like a Thunderclap Headache. A very important part of the diagnosis is that other conditions are excluded by brain scans and lumbar puncture. Heart disease can very occasionally cause an exercise induced headache (called Cardiac Cephalalgia). Exertional headache will require investigation, as it is estimated that the chance of an underlying structural problem in the brain in exertional headache is about one in five. Causes of Headache after ExerciseIn one series of 219 cases of after-exercise headache there was a 22% chance of one of the following causes (after Pascual 1996):
The other 171 cases had Primary Exertional Headache, including those with sexual activity headache. A recent report has also suggested that Spontaneous Intracranial Hypotension is another cause of headaches induced by exercise.
What tests should be performed?An exercise induced headache should be investigated with the following tests:MRI Brain scan is the best way to exclude Chiari Malformation or to see changes of intracranial hypotension. (A CT Scan of Head will do if you are able to do sagittal reconstructions of the foramen mangnum). Exercise Tolerance ECG (EKG) Test to look for evidence of cardiac disease. A Lumbar Puncture would be indicated if you suspected high or low intracranial pressure e.g. there were symptoms of pulsatile tinnitus or hyperacusis (intolerance of noise). TreatmentTreatment of exercise headaches (other than exercise avoidance) could include:
(Although none of these have been tested in randomised controlled trials, so strictly speaking are unproven). If an underlying cause it should be treated accordingly:
ReferencesPascual J et al. Cough, exertional and sexual headaches. An analysis of 72 benign and symptomatic cases. Neurology 1996;46:1520–4 (Free Abstract only)Sjaastad and Bakketeig. Exertional headache. I. Vågå study of headache epidemiology. Cephalalgia 2002;22:784-90 (Free Abstract only) Mokri B. Spontaneous CSF leaks mimicking benign exertional headachesCephalalgia 2002:22:780-783 (Free Abstract only)
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