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Headache - Cluster
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neurology channel |
Headache - Exertional
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WebMD |
Headache - Tension
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Mayo
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Neurology
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Neurobase
Synonyms: Exertional headache
Sub-topics: Benign exertional headache
Keywords: cough; effort; headaches; Valsalva maneuver
Historical note and nomenclature
In 1932, Tinel presented several patients with intermittent,
paroxysmal headaches following exertion and maneuvers that increased
the intrathoracic pressure (Tinel 1932). Later, Symonds called the
disorder "cough headache" and demonstrated that it may be a benign
syndrome without demonstrable cause (Symonds 1956).
Jokl described migraine occurring after exercise (Jokl 1965). His
description of this problem is graphic:
During my freshman year in medical school I ran as an anchor
man in the mile
relay team of my university and the German track championships of
Jena,
Thuringia. We won by the smallest possible margin. I was then 17
years old,
and this was the first time I had been clocked in under fifty
seconds. A few
minutes after the race my happiness over the victory was
interrupted by an
attack of nausea, headache, prolonged weakness and vomiting. It
lasted fifteen
minutes whereupon it quickly subsided. None of my professors were
able to
explain this episode, nor could I find appropriate reference in
any textbooks of
physiology or medicine.
The first large series published on exertional headache or head pain
related to exertion came from the Mayo Clinic (Rooke 1968).
Jokl and Jokl noted several profound cases of effort migraine
during the Olympic games in Mexico City (Dalessio 1974; Jokl and Jokl
1977). The high altitude was an obvious predisposing factor, as were
heat, humidity, and perhaps lack of training. Migraine after effort
tended to occur with prolonged running rather than sprints. These
highly conditioned athletes
developed scotomata, unilateral retro-orbital pain, nausea, and
vomiting,
and in some cases a striking prostration occurred.
A number of authors have included cough headache in the broader
context of exertional headache, but cough headache has clinical
features
that differentiate it from exertional headache and presumably has a
different
pathogenesis.
Clinical manifestation
An activity-related headache is one that occurs during or shortly
after physical activity. The benign varieties (ie, those unassociated
with cranial or intracranial pathology) may be classified into several
different categories (Dimeff 1992).
Activity-related headaches that appear to be caused by increased
venous pressure (cough headache): These headaches typically follow or
accompany activities—coughing, sneezing, bending over, laughing,
crying, heavy lifting, straining at stool—that incorporate the Valsalva
maneuver (Symonds 1956;
Rooke 1968; Ekbom 1986). Benign cough headaches (ie, those unassociated
with
any intracranial pathology) are sudden in onset, reach a peak intensity
rapidly, and then either disappear or fade to a dull ache that may
remain for several hours. The pain is moderate to severe in intensity,
with a sharp or stabbing quality (Pascual et al 1996). It is bilateral
in most patients. The major locus of pain can be in the occipital,
frontal, or temporal regions or at vertex with radiation to the frontal
regions bilaterally. It is usually
not associated with nausea or vomiting. Patients are usually pain-free
between attacks. Cough headache is provoked specifically by coughing,
sneezing,
or other such maneuvers, whereas other headache types (eg, migraine,
post-lumbar puncture headache) are often augmented by cough.
Exertion-produced vascular headaches: When seen in patients
without any cranial or intracranial pathology, this type of headache is
usually
referred to as "benign exertional headache" (Table 1). Headache during
or
following exertion implies that adequate physical activity has produced
the
requisite cephalgia. Mental effort, no matter how onerous, is not
included
here. How much effort, then, causes headache? Arbitrarily, enough to
double
the resting pulse for at least 10 seconds, but ordinarily for minutes
or
hours. Running, rowing, and tennis are reported causes. Several recent
papers
from Japan have emphasized exertional headache evoked by swimming (Indo
and
Takahashi 1990; Mizoguchi et al 1990).
Usually the headache is described as aching, pounding, or
throbbing, and has many characteristics of migraine, with associated
nausea, vomiting, and photophobia. It may be bilateral or unilateral
(Pascual et al 1996). Generally the headache occurs at the peak of
exercise and subsides as activity ceases. A more prolonged form of
exertional headache has been reported by Diamond (Diamond 1982b).
Heat, high humidity, conditions of changing barometric pressure,
exercise at high altitudes, caffeine, poor nutrition, hypoglycemia, and
alcohol
usage are believed to be contributing factors (Dalessio 1974).
Exertional headache occurs both in poorly conditioned persons who
exercise infrequently and in trained athletes.
The majority of cases occur in patients who have migraine or who
have a family history of migraine.
Diagnostic Criteria for Benign Exertional Headache
• Is specifically brought on by physical exercise
• Is bilateral, throbbing in nature at onset and may develop
migrainous features in those
patients susceptible to migraine
• Lasts from 5 minutes to 24 hours
• Is prevented by avoiding excessive exertion, particularly in
hot weather or at high altitude
• Is not associated with any systemic or intracranial disorder
(Headache Classification Committee of the International Headache Society 1988)
Weight lifter's headache: Intense pain that originates in the
occipital/nuchal region and radiates into the parietal area can occur
as a result of the maximal exertion during weight lifting (Powell
1982). The pain is steady and described as boring. It gradually
declines, leaving a residual ache that may lasts
days or weeks. This headache may be caused by stretching of the
cervical
ligaments and tendons with development of excessive muscle contraction.
Headaches associated with sexual activity: Headaches may occur
during sexual activities associated with intercourse or independent of
intercourse (eg, masturbation) or orgasm.
Cardiac cephalgia: Rare patients with arteriosclerotic coronary
artery disease may have exertional headaches beginning with vigorous
exercise
and relieved by rest (Lipton et al 1997; Lance and Lambros 1998).
Treadmill testing can reveal electrocardiographic changes appearing
with the headache.
Etiology
Cough headaches are reported by patients without any apparent
cause, but may be seen in patients with intracranial lesions including
posterior fossa tumors and foramen magnum lesions (Symonds 1956). The
presence of a Chiari malformation or another type of lesion (eg,
platybasia, basilar impression, cerebellar or cerebral tumor)
obstructing the CSF pathways must be ruled
out before cough headache can be considered to be benign in nature.
In approximately 10% of cases of headache precipitated by
exercise or excessive exertion, an organic lesion can be demonstrated
(Rooke 1968). The majority of these cases have a structural disorder at
the base of the brain (eg, Chiari malformation). Aneurysm is rare as
the primary lesion.
Other cases of intracranial pathology including primary brain tumor,
metastatic disease, and subarachnoid hemorrhage have been reported
(Pascual et al
1996). Pheochromocytoma or hypoplasia of the aortic arch after
successful
coarctation repair may occasionally be responsible for exertional
headache
(DeLeon et al 1997). Most patients have no demonstrable pathology.
Biological basis
A number of theories have been proposed to explain the pain
associated with exertion, but objective data are lacking in most cases
(Williams 1980; Diamond 1982a; Powell 1982). The acute onset of
headache with the Valsalva maneuver is most likely explained by
increased intracranial venous pressure (Williams 1976; 1980). The
Valsalva maneuver increases intrathoracic and intra-abdominal pressure
that is transmitted to epidural veins, producing a pressure wave that
moves CSF rostrally. The headache may be caused by
the temporary impaction of the cerebellar tonsils with traction on the
pain-sensitive dura when the patient stops the maneuver and the CSF
pressure gradient is reversed.
The etiology of benign exertional headache is presumed to be
related to cerebral vasodilatation, both extracranial and intracranial
in nature. In this respect exertional headache may resemble the
headaches associated with high altitude and fever. Of interest, HmPAO
SPECT of a young man with exertional headache revealed transient
hypoperfusion in the frontal lobes bilaterally (Basoglu et al 1996).
Weight lifter's headache may be caused by strain or stretch of
the cervical ligaments and tendons with development of excessive muscle
contraction.
Epidemiology
Rasmussen and Olesen have assessed the lifetime prevalences of
headache disorders in a cross-sectional epidemiologic survey of a
representative 25- to 64-year-old general population (Rasmussen and
Olesen 1992). They found a lifetime prevalence of 1% for benign
exertional headache. Judging from
the number of cases of cough headache in the literature, the problem is
probably an unusual one. Both benign cough headache and benign
exertional headache appear to be more frequent in men (Symonds 1956;
Rooke 1968).
Prevention
Where exertional headache is diagnosed, limitation of exercise
may be practiced. Improved overall physical conditioning and a warm-up
period before exercise may help in the prevention of exercise-induced
vascular headaches (Lambert and Burnet 1985).
Differential Diagnosis
An adequate history will usually reveal the diagnosis of
exertional headache, but exertion can produce headaches in patients
with mass lesions, structural malformations, and vascular
malformations. Rarely, exertional headache is a symptom of middle
cerebral artery dissection (Adams and Trevenen 1996). The diagnosis of
benign exertional headache can be made only after a thorough
examination to rule out intracranial disease or structural
malformation.
Diagnostic Workup
It seems evident that there are benign and malignant forms of
headache associated with cough and exercise. An MRI examination is
usually required to evaluate patients with exertional headache. If an
aneurysm is suspected, or if there is doubt, further neurologic studies
are indicated, particularly spinal puncture, CT scan of the head, MRA,
or contrast studies.
Prognosis and Complications
The prognosis for patients with benign forms of headache
associated with activity or exertion is good.
Management
Benign cough headaches may respond to indomethacin (25 to 50 mg
three times a day) (Mathew 1981). Raskin has recently reported the
response
of some patients to lumbar puncture (Raskin 1995).
For benign exertional headache, moderation of exercise or
activity is all that is usually required. The prophylactic use of
nonsteroidal drugs such as indomethacin in doses varying from 25 to 150
mg a day has been recommended for more prolonged exertional headaches
(Diamond and Medina 1979; Mathew 1981). Only rarely are prophylactic
drugs (methysergide, Inderal) used for migraine indicated in the
treatment of exercise-induced headaches.
Pregnancy
No information is available.
Anesthesia
This diagnosis does not preclude anesthesia as indicated or
necessary.
By: Robert A. Davidoff
Neurobase
First 2000 Edition
Copyright © 1993-2000 Arbor Publishing Corp. All rights
reserved