Headache in Athletes

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Headache in Athletes

• Kevin deWeber, MD, FAAFP
• Director, Sports Medicine Fellowship
• USUHS

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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

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Prevalence of headache in athletes

• 30 of adolescents (13-15) w/ exertional HA
• Cephalalgia 2008
• 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

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Consequences of Exertional HA

• Apprehension --gt decreased performance
• Limitation of activity
• Treatment medicines --gt performance

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Categories of HA in athletes

• Exertional Headache (EH)
• Primary (benign) EH
• Exertional migraine
• Cervicogenic EH
• Traumatic HA
• EH due to underlying conditions
• Intracranial hemorrhage
• Mass lesions
• Systemic conditions
• Medications

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Sport and exercise headache part 2. diagnosis
and classification. Br J Sports Med 1994
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Etiology of Exertional Headache

• 10-43 have underlying intracranial pathology

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Neurology referral clinic 10 of patients with
exertional headaches had an underlying organic
cause

• 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
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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
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Neurology referral clinic, 11 pts18 of EH were
from subarachnoid hemorrhage

• 82 were primary (benign)
• J Headache Pain 2008

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Evaluation ofExercise Induced Headache

• First objective is to rule out ominous etiologies
  
• Subarachnoid hemorrhage, cerebral aneurysm,
  Arnold-Chiari malformation, neoplasm, CNS
  infection, venous sinus stenosis

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Headache Red Flags

• 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

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Headache Red Flags (cont.)

• 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

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Evaluation of the acute, severe headache
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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

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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.
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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 Ive ever had
• thunderclap headache

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Intracranial HemorrhageManagement

• Take athlete immediately to ED
• CT scan, LP if negative
• Neurosurgical referral

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Mass lesion headache

• 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

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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 Valsalva-induced HA
  have intracranial lesion
• CT or MRI indicated

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Exercise-induced headache from systemic conditions

• Hypoglycemia
• Hypertension
• Dehydration
• Sinus disease
• Hyperthermia
• Pheochromocytoma
• Cardiac ischemia (cardiac cephalgia)

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Medication-relatedexercise-induced headache

• Thermogenic (weight loss) aids
• Anabolic steroids
• Stimulants

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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

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Trauma Induced Migraine

• Terrell Davis in Superbowl 32 in 1998
• Migraine from kick to the head

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Migraine headacheAbortive treatment

• Acetaminophen/NSAIDs work in a few
• Specific abortive meds needed in most
• Triptans (5-HT1 agonists)
• Ergotamine agents
• Antiemetics
• Butorphanol nasal spray
• Intranasal lidocaine 4 drops

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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
• Sumatriptan (SC, oral, nasal spray)
• Rizatriptan (oral)
• Zolmitriptan (oral)
• Naratriptan (oral)

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Migraine headache Abortive treatment (cont.)

• Side effects of Triptans
• Somnolence, atypical pain, dizziness
• Rest in quiet, dark room is helpful
• Repeat prn as indicated
• Return to play is possible if HA aborted
• Contra-indications
• CAD, uncontrolled HTN, Prinzmetals angina

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Migraine headacheAbortive 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

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Migraine headacheProphylaxis

• Indications
• More than 1-2 HAs/month
• HAs not responsive to abortive treatment
• HAs 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

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Migraine headacheProphylactic 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

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Migraine headacheProphylactic meds with higher
side effect profiles but quite effective

• Nortriptaline - 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
  effects

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Primary exertional headache

• Precipitated by any form of exercise
• Running, swimming, cycling, skiing most often
  implicated
• Etiology ? Cerebrovasculat dilation
• Develops during or after exercise
• Intensity builds as exercise continues
• Tends to be diffuse and pulsating
• Often with migrainous symptoms
• Last 5 min to 2 days
• Not due to underlying disorder

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Primary (Benign) Exertional Headache

• Should be a diagnosis of exclusion

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Primary exertional headacheWorkup

• Strongly consider CT or MR imaging on first
  occurrence, especially if red flags present

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Primary exertional headacheTreatment and
prevention

• Effectively treated with NSAIDs
• Consider prophylactic meds if recurrent
• Triptans
• Beta-blockers
• NSAIDs
• Ergotamine

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Cervicogenic EHWeight Lifters 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

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Cervicogenic EHTreatment

• Ice
• Analgesics
• Massage
• Physical therapy modalities
• Manipulation

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Altitude Headache

• Occurs at altitude gt2500 meters
  in those not acclimatized
• Component of Acute Mountain Sickness
• Severe -- High Altitude Cerebral Edema
• Throbbing, generalized

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Altitude HeadacheTreatment

• Prevention
• 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

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Divers headache

• Multi-factorial
• Hypercapnia
• Cold stimuli
• Decompression sickness (bad)
• Excessive gripping of mouthpiece
• Sinus barotrauma
• Tight goggles, helmet
• Mask squeeze
• Getting hit on head by pipe

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Post-traumatic Headache types

• Intracranial bleed
• Chronic muscle contraction
• Tension-vascular
• Migraine (footballers)
• Dysautonomic cephalgia
• Post-concussion syndrome HA
• Local nerve entrapment

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Post-traumatic HeadacheChronic muscle
contraction

• May be component of Postconcussion Syndrome
• Treat as tension HA

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Post-traumatic HeadacheFootballers 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

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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

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Posttraumatic HeadachePost-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)

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Exacerbation of pre-existing headache syndromes

• Migraines, tension HA, mixed, cluster
• Treat as usual

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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,
  Arnold-Chiari malformation, neoplasm, CNS
  infection
• Remember HA red flags

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Headache Red Flags

• 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

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Headache Red Flags (cont.)

• 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

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QUESTIONS?