Understanding Post-Exercise Migraine And Exertional Headache

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Exertional headache

An exertional headache is brought on by physical activity. This usually means strenuous exercise, but some get exertional headaches from sexual activity or coughing. These seem to be caused by similar factors.

While migraines can be triggered by exercise, exertional headache is also its own thing and can exist without migraine, although it's often comorbid with it. Exertional headaches are split into two categories.

Primary exertional headache

This is a headache not associated with any kind of underlying condition. Primary exertional headaches are considered harmless, although they can have health impacts when they cause you to avoid physical activity. They are certainly unpleasant and warrant treatment.

Secondary exertional headache

These headaches are caused by an underlying condition, and many of the conditions that can cause them are serious. You should always see your doctor for exertional headaches, especially if they have only started recently. Your doctor can eliminate dangerous underlying conditions. This includes if you have migraines.

Note that exertional headache caused by migraine alone is not considered secondary but is classed as exercise-induced migraine.

Symptoms

By definition, a headache presenting upon exertion is a symptom, but it is diagnosed from the following factors.

Common symptoms

The primary symptom of an exertional headache is moderate to severe throbbing (pulsative) pain that starts during or after physical activity.

Unlike migraine headaches, typically only on one side, exertional headaches can be felt across the entire head. They are often mistaken for migraine when only on one side. These headaches can last from five minutes to 48 hours and are not associated with nausea or vomiting. They are also more likely to occur in hot weather and high altitudes.

Symptoms of primary exertional headache

With primary exertional headache, the headache itself is typically the only symptom, and it is self-limiting. It can last anywhere from a few minutes to two days. Additionally, primary exertional headaches often go away after a few months, although they may come back.

Migraines caused by exercise, on the other hand, need to be treated.

Symptoms of secondary exertional headache

Secondary exertional headache is more serious. Watch for these additional symptoms:

A doctor can help with exertional headaches by looking for underlying symptoms and providing tips on coping.

Causes

Although the exact mechanism of exercise headache is not well understood, it is thought to stem from the transmission of intraabdominal and intrathoracic pressure increases into the cranium, ultimately distending or tracking pain-sensitive meningeal or vascular structures.

Causes of primary exertional headache

Primary exertional headache is similar to migraine. It is likely caused by pressure increases affecting vascular and meningeal structures. However, it is more likely to be bilateral.

It is typically triggered by strenuous exercise, especially weight lifting and similar. Research is still being done to narrow down the exact cause of exertional headaches and potentially develop better ways to prevent and treat them.

Causes of secondary exertional headache

Secondary exertional headaches can be caused by many health conditions, some of which are very serious. It is triggered by the same factors as primary exertional headache.

Here are some conditions that can cause a secondary exertional headache:

  • Intracranial hemorrhage

  • Tumors (supratentorial and posterior fossa space-occupying lesions)

  • Cardiogenic headache may be triggered by exertion in patients with risk factors for coronary disease, including those without chest pain or evidence of ischemia on electrocardiogram (ECG)

  • Structural abnormalities of the head, neck, or spine

  • Sinus infections

  • Obstruction of the flow of cerebrospinal fluid causing fluid buildup around the brain

  • Vascular abnormalities, such as a cerebral aneurysm or arteriovenous malformation

  • Pheochromocytoma related headache

Because of some of these severities, it's vital to see a doctor if you start getting headaches after physical activity. Fortunately, most are easy to diagnose.

Who is at risk of experiencing an exertional headache?

Exertional headaches can be experienced by anyone who engages in physical activity, but some factors increase your risk. These include:

  • Having migraines

  • Being female

  • Cyclists

  • Living in a hot climate. You can reduce your risk of getting an exertional headache by exercising in the early morning or late evening when temperatures are lower. (Additionally, exercising in a hot climate can result in dehydration, which can give you a headache).

  • Living or exercising at a high altitude. Note that if you travel to a high altitude and get a headache, this could be acute mountain sickness (AMS). AMS is worsened by exertion, so it is easy to mistake one for the other. AMS has other symptoms, including insomnia, nausea, lack of appetite, dizziness, fatigue, and weakness, and the headache is typically diffuse and constant, worsening with straining and lifting. AMS headaches can be treated with ibuprofen and hydration and by acclimating to altitude carefully. However, even people who live at high altitudes face a higher risk of both exertional headaches and migraine.

Again, anyone can experience an exertional headache.

Diagnosis

If you have exertional headaches, your doctor will order a series of tests to identify or eliminate potential underlying conditions that might cause them. They will also likely ask you when you get the headaches, how long they last, and whether specific activities trigger them. The tests they might order are:

CT scan

A CT scan can check for recent bleeding in or around the brain. This can easily identify any bleeding, which may need to be treated immediately. It can also identify deformities of the skull that could contribute to your headaches and may find some tumors.

MRI scan

You may get an MRI scan to view the structures within your brain, looking for tumors or deformities of the skull that could be contributing to your headaches. The images produced tend to be very detailed and can spot even small abnormalities.

Magnetic resonance angiography and/or CT angiography

These two tests are used to check the blood vessels in your brain to see if they are physically wider or narrower than they should be. Magnetic resonance angiography is similar to an MR scan but focuses on blood vessels, looking for narrowing and obstruction or other such issues. 

CT angiography is very similar and uses the actual CT scanner. The two scans may reveal slightly different things, so some doctors will order both. Both may involve the injection of harmless contrast fluid to make blood vessels more obvious.

Spinal tap

Finally, you may have a spinal tap done to ensure that cerebrospinal fluid is flowing correctly. This slightly more invasive procedure involves using a thin, hollow needle and possibly fluoroscopy guidance to take a small sample of your cerebrospinal fluid and possibly measure the fluid pressure in the spinal canal. It is typically done under local anesthesia.

If you have a personal or family history of heart disease, your doctor will look at your heart to see if your headaches are a symptom of heart disease. It is not unknown for headaches to be the only symptom.

Treatment

Secondary exertional headache is treated by treating the underlying condition. If the condition is resolved, the headaches will go away. If your headaches are migraines, you may receive a recommendation to take certain medications before exercise or sex to reduce your risk.

Treatment might also include avoidance, which means avoiding specific activities that cause headaches. It is unhealthy to avoid exercise altogether, but you can change your exercise routine to avoid them unless they are central to your training. If your headaches are associated with sexual activity, you can try sexual positions that require less physical exertion, and you may find certain positions are okay and others should be avoided.

Some people may need medication to deal with their exertion headaches, depending on the severity of the headaches and how well other interventions work. Little treatment may be required for very mild exertional headaches depending on the duration and your tolerance.

Medication

You may be given medication before exercise to keep the headache from developing. The most common treatment is indomethacin, which you should take 30 to 60 minutes before exercise. Be aware that these medications can cause stomach irritation, and you need to keep an eye on yourself to make sure that you are not developing problems. Other treatments used include:

Oral indomethacin

Oral indomethacin is an NSAID that can be taken daily but is typically only recommended before exercise unless one exercises daily. You might also get a prescription for a medication to prevent stomach irritation and ulcers.

Beta-blockers

These are taken before exercise and are typically prescribed for those who can't take naproxen or indomethacin, for example, because they are prone to ulcers.

If you have migraines, your doctor might alternatively recommend adjusting the timing of the dosage of prophylactic medication. The mechanism underlying exertional headache appears to be similar, and it can sometimes be hard to tell the difference between primary exertional headache and migraine. However, if the headache is on both sides, it is almost certainly an exertional headache.

Prevention

It's not always easy to prevent exertional headaches. One way to lower your risk is to exercise in the early morning or late evening if you live in a hot climate. Exercising in extreme heat is a fairly strong risk factor.

Don't let exertional headaches or concerns about them stop you from exercising, especially if you get migraines. For most adults with migraines, regular exercise lowers the number of episodes you get.

When should you visit a doctor?

If you start getting exertional headaches, you should see your doctor immediately. It's vital to eliminate potentially dangerous underlying conditions and to identify them quickly so you can start treatment.

If there is no underlying condition, your doctor can help you find ways to stop the headaches, whether it's through medication or through changing how you work out. If you are in training, consider also talking to your coach, who may also have some advice. However, only do so after you have talked to your doctor and established that you do not have an underlying condition.

The lowdown

True exertional headaches are not migraines, but some people have migraines triggered by exercise, and people with migraines are at a higher risk of developing exertional headaches.

Any headache after exercise or physical activity should be taken seriously. You should go to your doctor to be checked for potentially dangerous secondary conditions. However, in most cases, it is a primary exertional headache, which is self-limiting and can easily be treated with medications and adjustments to your exercise routine.

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